Policy Type: Statement

Adopted by the 44th World Medical Assembly Marbella, Spain, September 1992
and rescinded at the WMA General Assembly, Pilanesberg, South Africa, 2006

The World Medical Association, Inc. previously adopted strategies to cope with the HIV epidemic, including physician’s avoidance of discrimination toward HIV infected patients, provision of care to those infected, an HIV-infected physician’s responsibility to avoid infection to a patient, issuing no false certificates, compliance with infection control procedures, cooperation with public authorities in prevention programs, development of national policies and programs, counseling patients to avoid HIV infection or, if infected, to avoid infecting others, wide availability of HIV testing especially for those likely to be infected, mandatory testing in certain circumstances such as blood donations, reporting cases of AIDS and HIV infection, balancing the rights of the infected patient with the rights of the uninfected, confidentiality of patient medical information, and research to establish the prevalence and incidence of HIV.

The number of persons with HIV infection and those who have progressed to AIDS has grown steadily. By the year 2000 an estimated 40 million persons worldwide will be infected with HIV. The World Medical Association therefore expresses a continuing concern that National Medical Associations take an active role in policy and programs of prevention, treatment and research. The World Medical Association adds the following to its previous recommendations:

  1. That the National Medical Associations, in cooperation with all segments of society and government, develop and implement a comprehensive program of HIV prevention, treatment, and research.
  2. That the National Medical Associations work with all media and forms of communication to assure a coordinated program of prevention, treatment awareness, and public compassion toward the infected.
  3. That National Medical Associations advise physicians of their responsibility to inform their patients as thoroughly as possible of the consequences of testing positive. In so informing their patients, physicians should use tact and delicacy, and have due consideration for the patients psychological condition.
  4. That the National Medical Associations assist in the training and education of physicians in the current medical treatments available for all stages of HIV infection and in the use of proper infection control procedures and universal precautions as outlined by the centers for disease control.
  5. That the National Medical Associations insist on the need for biological, clinical and psychological medical education relating to HIV-infected patients, to help physicians give effective care to their patients.
  6. That the National Medical Associations encourage physicians to help their patients assess the risks of HIV infection and to take appropriate prevention measures.
  7. That the National Medical Associations review and encourage improved infection control procedures in hospitals and other medical facilities.
  8. That the National Medical Associations review and encourage improvement in HIV diagnosis and treatment for women and children.
  9. That the National Medical Associations encourage the use of those public health techniques which have been successful in the past in dealing with infection epidemics especially those of sexually transmissible diseases.
  10. That the link of drug abuse to HIV transmission is an additional ground for National Medical Associations to further encourage drug abuse treatment.
  11. That the National Medical Associations seek to join with other medical, professional and health organizations to develop worldwide strategies for cooperation in prevention, treatment and research on HIV especially those that may be carried out by professional societies.

Adopted by the 40th World Medical Assembly Vienna, Austria, September 1988
and rescinded at the WMA General Assembly, Pilanesberg, South Africa, 2006

The World Medical Association, Inc. has previously adopted guidelines to assist National Medical Associations in developing strategies to cope with a growing AIDS epidemic. This statement provides the individual physician with direction as to his or her professional responsibilities with reference to the treatment of AIDS patients, and also as to the physician’s responsibility to his or her patients in the event the physician is seropositive.

The WMA Interim Statement on AIDS, adopted in October 1987, states in part:
“Patients with AIDS and those who test positively for the antibody to the AIDS virus must be provided with appropriate medical care and should not be treated unfairly or suffer from arbitrary or irrational discrimination in their daily lives. Physicians have a long and honored tradition of tending to patients afflicted with infectious diseases with compassion and courage. That tradition must be continued throughout the AIDS epidemic.”

AIDS patients are entitled to competent medical care with compassion and respect for human dignity. A physician may not ethically refuse to treat a patient whose condition is within the physician’s current realm of competence, solely because the patient is seropositive. Medical ethics do not permit categorical discrimination against a patient based solely on his or her seropositivity. A person who is afflicted with AIDS needs competent, compassionate treatment. A physician who is not able to provide the care and services required by persons with AIDS should make an appropriate referral to those physicians or facilities that are equipped to provide such services. Until the referral can be accomplished, the physician must care for the patient to the best of his or her ability.

The rights and interests of those who are infected with the AIDS virus, as well as those who are not, are entitled to protection. A physician who knows that he or she has an infectious disease should not engage in any activity that creates a risk of transmission of the disease to others. In the context of possible exposure to AIDS, the activity in which the physician wishes to engage will be the controlling factor.

In the provision of medical care, if a risk of transmission of an infectious disease from a physician to a patient exists, disclosure of that risk to patients is not enough; patients are entitled to expect that their physicians will not increase their exposure to the risk of contracting an infectious disease.

If no risk exists, disclosure of the physician’s medical condition to his or her patients will serve no rational purpose; if a risk does exists, the physician should not engage in that activity.

If a patient is fully informed of the physician’s condition and the risks that condition presents, and the patient elects to continue care and treatment with the seropositive physician, great care must be exercised to assure that true informed consent is obtained.

The duty of all physicians is to refrain from issuing false certificates even if the intention of such is to help the patients to stay within his regular environment.

The duty of the physician is to comply with and make comply the sanitary and protective rules established for health personnel because they are known, simple and effective.

The duty of all physicians is to participate fully in preventive programs initiated by public authorities to stop the spread of AIDS.

Adopted by the 39th World Medical Assembly Madrid, Spain, October 1987
and rescinded at the WMA General Assembly, Pilanesberg, South Africa, 2006

In-Vitro Fertilization and Embryo Transplantation is a medical technique which is available for the treatment of infertility in many parts of the world. It has the potential to benefit both individual patients and society generally, not only by the alleviation of infertility, but also by the possible avoidance of genetic disorders and by enhancing fundamental studies of human reproduction and contraception.

The WMA urges physicians to act ethically and with appropriate respect for the health of the prospective mother and for the embryo from the beginning of life. To assist physicians in recognizing and following their ethical obligations, the WMA has promulgated this statement.

From the ethical and scientific viewpoint, medical assistance in human reproduction is justified in all cases of infertility which do not respond to classical drug or surgical treatment with specific reference to:

  1. immunological incompatibility
  2. irreversible obstacle to contact between male and female gametes
  3. infertility for unknown cause

In all these cases, the physician can only act with the full informed consent of donors and recipients. The physician must always act in the best interest of the child to be born of the procedure.

It is the physician’s responsibility to provide the patients, at their own level of comprehension, with sufficient information about the purpose, methods, risks, inconveniences and disappointments of the procedure, and to obtain from the patients their informed consent to the procedure. As in any type of elective procedure, the physician must have adequate specialized training before undertaking the responsibility of performing the procedure. The physician must always comply with all applicable laws and regulations as well as the ethical requirements and the professional standards established by the National Medical Association and other appropriate medical organizations in the community. The patients are entitled to the same confidentiality and privacy as is required with any medical treatment.

When IVF techniques produce excess ova which will not be utilized for the immediate treatment of sterility, their use must be determined in agreement with the donors; excess ova can be:

  1. destroyed
  2. cryopreserved
  3. fertilized and cryopreserved

Scientific knowledge concerning maturation, fertilization and first stages of pluricellular development processes is still in an early stage. It is therefore appropriate to continue study and experimentation of the physical and chemical phenomena in this field strictly in accordance with the Declaration of Helsinki, and with the written consent of the donors.

RESEARCH

The technique of in vitro fertilization and embryo transplantation can also be useful in research directed towards a better understanding of how genetic defects arise and are transmitted, and how they might be prevented or treated. Profound moral and ethical implications may arise for both the physician and the patient. The physician should not violate his personally held moral principles and must be sensitive to, and respect, the moral and ethical principles held by patients. The physician has a greater responsibility to communicate fully with the patients who will participate in the research effort and the informed consent of those patients must meet the requirements of law as well as the special level of professional responsibility dictated by ethical standards. The principles of the World Medical Association’s Declaration of Helsinki will apply to all clinical research in respect to in-vitro fertilization and embryo transplantation, as well as all problems that arise out of such clinical research.

The World Medical Association recommends that physicians refrain from intervening in the reproduction process for the purpose of making a choice as to the foetus’ sex, unless it is to avoid the transmission of serious sex-linked disease.

DONATION

The technique of in-vitro fertilization and embryo transplantation creates the possibility of donation of ova, sperm, and embryo, so that the biological donors may not be the parents of the child produced by this procedure. Such use of donated gametes or embryo may present serious legal, moral, and ethical issues for both patients and physicians involved in such in-vitro fertilization and embryo transplantation procedures. The physician must observe all applicable laws and ethical restrictions imposed by the National Medical Association or other appropriate medical organizations. The physician must also be sensitive to, and respect, the moral and ethical principles of patients, and refrain from the use of donated gametes or embryos when it would conflict with legal or ethical restrictions or the moral principles of the patients. The physician has the right to refuse any intervention he or she deems unacceptable.

The technique of cryo-preservation increases the availability of gametes and embryos for donation. Where permitted, if one or more donors of gametes, or the donors of an embryo, will not be the functional parent(s) of the prospective child, the physician must obtain assurance that the recipients will accept full responsibility for the unborn child and that the donors will renounce all rights or claims to the unborn child without prejudice to the rights of the child when born.

In the case of an adult woman who is without a uterus, the use of the so-called method of substitute or surrogate motherhood may be used unless prohibited by applicable laws or the ethical rules of the National Medical Association or other appropriate medical organizations. Free and informed consent must be obtained from the parties who are participating in any way in such substitute or surrogate method. There are legal, ethical and moral implications in the use of such method of substitute or surrogate motherhood and the physician must recognize them and consider them as part of any decision to use such method.

The preceding paragraph is not intended to endorse the so-called “Surrogate Parenting” arrangement by which a woman agrees, for a fee, to be artificially inseminated with the sperm of a man for the purpose of conceiving a child who will be adopted by the man and his wife.

Any commercialization by which ova, sperm, or embryo are offered for purchase or sale is expressly condemned by the World Medical Association.

Adopted by the 67th World Medical Assembly, Taipei, Taiwan, October 2016 

PREAMBLE

  • Advancements in modern information technology (IT) pave the way for improvements in healthcare delivery and help streamline physician workflow, from medical record keeping to patient care. At the same time, implementing new and more sophisticated IT infrastructure is not without its challenges and risks, including cyber-attacks and data breaches.
  • Cyber security threats are an unfortunate reality in an age of digital information and communication. Attacks on critical infrastructure and vital assets of public interest, including those used in the fields of energy, food and water supply, telecommunications, transportation and healthcare, are on the rise and pose a serious threat to the health and well-being of the general public.
  • With the proliferation of electronic medical records and billing systems, the healthcare sector is especially susceptible to cyber intrusions and has become a prime soft target for cyber criminals. Healthcare institutions and business partners, from the smallest of private practices to the largest of hospitals, are vulnerable not only to the theft, alteration and manipulation of patients’ electronic medical and financial records, but also to increasingly sophisticated system breaches that could jeopardise their ability to provide care for patients and respond to health emergencies. Especially disconcerting is the threat posed to a patient’s fundamental right to data privacy and safety. In addition, repairing the damage caused by successful cyber-attacks can entail significant costs.
  • Patient data also demands protection because it often contains sensitive personal information that can be used by criminals to access bank accounts, steal identities, or obtain prescriptions illegally. For this reason, it is worth far more on the black market than credit card information alone. Alterations to or abuse of patient data in the case of a breach can be detrimental to the health, safety and material situation of patients. In some cases, breaches can even have life-threatening consequences.
  • Current security procedures and strategies in the healthcare sector have generally not kept pace with the volume and magnitude of cyber-attacks. If not adequately protected, hospital information systems, practice management systems or control systems for medical devices can become gateways for cybercriminals. Radiology imaging software, video conferencing systems, surveillance cameras, mobile devices, printers, routers and digital video systems used for online health monitoring and remote procedures are just some of the many IT structures at risk of being compromised.
  • Despite this danger, many healthcare organisations and institutions lack the financial resources (or the will to provide them) and the administrative or technical skills and personnel required to detect and prevent cyber-attacks. They may also fail to adequately communicate the seriousness of cyber threats both internally and to patients and external business partners.

RECOMMENDATIONS

  1. The WMA recognises that cyber-attacks on healthcare systems and other critical infrastructure represent a cross-border issue and a threat to public health. It therefore calls upon governments, policy makers and operators of health and other vital infrastructure throughout the world to work with the competent authorities for cyber security in their respective countries and to collaborate internationally in order to anticipate and defend against such attacks.
  2. The WMA urges national medical associations to raise awareness among their members, health care institutions and other industry stakeholders about the threat of cyber-attacks and to support an effective, consistent healthcare IT strategy to protect sensitive medical data and to assure patient privacy and safety.
  3. The WMA underscores the heightened risk of cyber intrusions and other data breaches faced by the healthcare sector and urges medical institutions to implement and maintain comprehensive systems for preventing security breaches, including but not limited to providing training to ensure employee compliance with optimal data handling practices and to maintain security of computing devices. 
  4. In the event of a data security breach, healthcare institutions should have proven response systems in place, including but not limited to notifying and offering protection services to victims and implementing processes to correct errors in medical records that result from malicious use of stolen data. Data breach insurance policies could be considered as a precautionary measure for defraying the costs associated with a potential cyber intrusion.
  5. The WMA calls upon physicians, as guardians of patient safety and data confidentiality, to remain aware of the unique challenge cyber-attacks could pose to their ability to practice their profession and to take all necessary measures that have been shown to safeguard patient data, patient safety and other vital information.
  6. The WMA recommends that undergraduate and postgraduate medical education curricula include comprehensive information on how physicians can use modern IT and electronic communications systems to full advantage, while still ensuring data protection and maintaining the highest standards of professional conduct.
  7. The WMA acknowledges that physicians and healthcare providers may not always have access to the resources (including financial), infrastructure and expertise required to establish fail-safe defence systems and stresses the need for the appropriate public as well as private bodies to support them in overcoming these limitations.

Adopted by the 67th WMA General Assembly, Taipei, Taiwan, October 2016

PREAMBLE

  • As noted by the 65th World Medical Assembly in Durban in 2014, physicians around the world are aware that fossil fuel air pollution reduces quality of life for millions of people worldwide, causing a substantial burden of disease, economic loss, and costs to health care systems.
  • According to World Health Organization data, in 2012, approximately “7 million people died, one in eight of total global deaths, as a result of air pollution” (WHO, 2014).
  • The United Nations’ Intergovernmental Panel on Climate Change (IPCC) notes that global economic and population growth, relying on an increased use of coal, continues to be the most important driver of increases in Carbon Dioxide emissions.  These emissions are the major component of an accelerating the amount of human fossil fuel Greenhouse Gas (GHG) emissions despite the adoption of climate change mitigation policies (IPCC, 2014).
  • The burden of disease arising from Climate Change will be differentially distributed across the globe and, while it will affect everyone, the most marginal populations will be the most vulnerable to the impacts of climate change and have the least capacity for adaptation.

BACKGROUND

  • In many densely settled populated cities around the world, the fine dust measurable in the air is up to 50 times higher than the WHO recommendations. A high volume of transport, power generated from coal, and pollution caused by construction equipment are among the contributing factors (WMA, SMAC 197, Air Pollution WMA Statement on the Prevention of Air pollution due to Vehicle Emissions 2014).
  • Evidence from around the world shows that the effects of climate change and its extreme weather are having significant and sometimes devastating impacts on human health.   Fourteen of the 15 warmest years on record have occurred in the first 15 years of this century (World Meteorological Organization 2014).  The vulnerable among us including children, older adults, people with heart or lung disease, and people living in poverty are most at risk from these changes.
  • The WMA notes the Lancet Commission’s description of Climate Change as “the greatest threat to human health of the 21st century”, and that the Paris agreement at COP21 on Climate calls upon governments “when taking action on climate change” to “respect, promote and consider their respective obligations on human rights (and) the right to health”.
  • As the WMA states in its Delhi Declaration on Health and Climate Change, “Although governments and international organizations have the main responsibility for creating regulations and legislation to mitigate the effects of climate change and to help their populations adapt to it, the World Medical Association, on behalf of (…) its physician members, feels an obligation to highlight the health consequences of climate change and to suggest solutions. (…) The WMA and NMAs should develop concrete actionable plans/practical steps” to both mitigate and adapt to climate change (WMA 2009).

RECOMMENDATIONS

The WMA recommends that its national medical associations and all health organizations:

  1. Continue to educate health scientists, businesses, civil society, and governments concerning the benefits to health of reducing greenhouse gas emissions and advocate for the incorporation of health impact assessments into economic policy.
  2. Encourage governments to adopt strategies that emphasize strict environmental regulations and standards that encourage energy companies to move toward renewable fuel sources.
  3. Begin a process of transferring their investments, when feasible without damage, from energy companies whose primary business relies upon extraction of, or energy generation from, fossil fuels to those generating energy from renewable energy sources.
  4. Strive to invest in companies upholding the environmental principles consistent with the United Nations Global Compact (www.unglobalcompact.org), and refrain from investing in companies that do not adhere to applicable legislation and conventions regarding environmental responsibility.
Within the framework of the Health Care in Danger project, the World Medical Association (WMA), the International Committee of Military Medicine (ICMM), the International Council of Nurses (ICN) and the International Pharmaceutical Federation (FIP) were consulted by the ICRC with the aim of these organizations agreeing on a common denominator of ethical principles of health care applicable in times of armed conflict and other emergencies. These principles, which are the result of these consultations, are without prejudice to existing policy documents adopted by these organizations. 

The “Ethical Principles of Health Care in Times of Armed Conflict and Other Emergencies” were adopted by the 65th General Assembly of the WMA, Durban (South Africa), October 2014 and officially launched by all partners in June 2015.

Adopted by the 66th WMA General Assembly, Moscow, Russia, October 2015
and rescinded and archived by the 73rd WMA General Assembly, Berlin, Germany, October 2022

PREAMBLE

Mobile health (mHealth) is a form of electronic health (eHealth) for which there is no fixed definition. It has been described as medical and public health practice supported by mobile devices, such as mobile phones, patient monitoring devices, personal digital assistants (PDAs), and other devices intended to be used in connection with mobile devices. It includes voice and short messaging services (SMS), applications (apps), and the use of the global positioning system (GPS).

Sufficient policies and safeguards to regulate and secure the collection, storage, protection and processing of data of mHealth users, especially health data, must be implemented. Users of mHealth services must be informed about how their personal data is collected, stored, protected and processed and their consent must be obtained prior to any disclosure of data to third parties, e.g. researchers, governments or insurance companies.

The monitoring and evaluation of mHealth should be implemented carefully to avoid inequity of access to these technologies. Where appropriate, social or healthcare services should facilitate access to mHealth technologies as part of basic benefit packages, while taking all the required precautions to guarantee data security and privacy. Access to mHealth technologies should not be denied to anyone on the basis of financial status or a lack of technical expertise.

mHealth technologies cover a wide spectrum of functions. They may be used for:

  • Health promotional (lifestyle) purposes, such as apps into which users input their calorie intake or motion sensors which track exercise.
  • Services which require the medical expertise of physicians, such as SMS services providing advice to pregnant women or wearable sensors to monitor chronic conditions such as diabetes. mHealth technologies of this nature frequently meet the definition of a medical device and should be subject to risk-based oversight and regulation with all its implications.

mHealth may also be used to expedite the transfer of information between health professionals, e.g. providing physicians with free, cross network mobile phone access in resource poor settings.

Technological developments and the increasing prevalence and affordability of mobile devices have led to an exponential increase in the number and variety of mHealth services in use in both developed and developing countries. At the same time, this relatively new and rapidly evolving sector remains largely unregulated, a fact which could have potential patient safety implications.

mHealth has the potential to supplement and further develop existing healthcare services by leveraging the increasing prevalence of mobile devices to facilitate access to healthcare, improve patient self-management, enable electronic interactions between patients and their physicians and potentially reduce healthcare costs. There are significant regional and demographic variations in the potential use and benefits of mHealth. The use of certain mHealth services may be more appropriate in some settings than others.

mHealth technologies generally involve the measurement or manual input of medical, physiological, lifestyle, activity and environmental data in order to fulfil their primary purpose. The large amount of data generated in this way also offers huge scope for research into effective healthcare delivery and disease prevention. However, this secondary use of personal data also has great potential for misuse and abuse, of which many users of mHealth services are unaware.

The expansion of mHealth services has been largely market driven and many technologies have been developed in an uncoordinated, experimental fashion and without appropriate consideration of data protection and security or patient safety aspects. It is often impossible for users to know whether the information provided via mHealth stems from a reliable medical source. Major challenges faced by the mHealth market are the quality of mHealth technologies and whether their use ultimately helps patients or physicians achieve the intended purpose.

Comprehensive regulation and evaluation of the effectiveness, quality and cost effectiveness of mHealth technologies and services is currently lacking, which has implications for patient safety. These factors are crucial to the integration of mHealth services into regular healthcare provision.

RECOMMENDATIONS

The WMA recognises the potential of mHealth to supplement traditional ways of managing health and delivering healthcare. While mHealth may offer advantages to patients otherwise unable to access services from physicians, it is not universally appropriate, nor is it always an ideal form of diagnosis and treatment option. Where face-to-face treatment is available this is almost always advantageous to the patient.

The driving force behind mHealth must be the need to eliminate deficiencies in the provision of care or to improve the quality of care.

The WMA urges patients and physicians to be extremely discerning in their use of mHealth and to be mindful of potential risks and implications.

A clear distinction must be made between mHealth technologies used for lifestyle purposes and those which require the medical expertise of physicians and meet the definition of medical devices. The latter must be appropriately regulated and users must be able to verify the source of information provided. The information provided must be clear, reliable and non-technical, and therefore comprehensible to lay people.

Concerted work must go into improving the interoperability, reliability, functionality and safety of mHealth technologies, e.g. through the development of standards and certification schemes.

Comprehensive and independent evaluations must be carried out by competent authorities with appropriate medical expertise on a regular basis in order to assess the functionality, limitations, data integrity, security and privacy of mHealth technologies. This information must be made publicly available.

mHealth can only make a positive contribution towards improvements in care if services are based on sound medical rationale. As evidence of clinical usefulness is developed, findings should be published in peer reviewed journals and be reproducible.

Suitable reimbursement models must be set up in consultation with national medical associations and healthcare providers to ensure that physicians receive appropriate reimbursement for their involvement in mHealth activities

A clear legal framework must be drawn up to address the question of identifying potential liability arising from the use of mHealth technologies.

Physicians who use mHealth technologies to deliver healthcare services should heed the ethical guidelines set out in the WMA Statement on Guiding Principles for the Use of Telehealth for the Provision of Health Care.

It is important to take into account the risks of excessive or inappropriate use of mHealth technologies and the potential psychological impact this can have on patients.

Adopted by the 66th WMA General Assembly, Moscow, Russia, October 2015

PREAMBLE

There has been a long-standing concern regarding the use of chemical weapons. Despite this concern, poison gas was used fairly extensively during World War I, leading to a call from the International Committee of the Red Cross (ICRC) in February 1918 for cessation of its use.

This led to the Geneva Protocol of 1925, the Biological and Toxin Weapons Convention of 1972 (BTWC) and the Chemical Weapons Convention of 1993 (CWC).

All but six countries in the world have signed and ratified the CWC; two more have signed but not yet ratified, making it a nearly universally accepted Convention.

The conventions prohibit the development, production and stockpiling of chemical weapons in addition to their usage in warfare and call for measures to decommission or destroy existing stores. However, the CWC allows the use of specific chemicals in domestic law enforcement including riot control situations, which means that governments might hold stockpiles of certain agents. Even so, riot control agents cannot be used in warfare; the exclusion has reached the status of customary law, which allows their use only in domestic or national jurisdictions.

Although there is academic and military interest in what is often called non-lethal weapons, the incidence of morbidity and mortality caused by weapons are not criteria used in prohibition. A tiered approach based upon degrees of lethality of specific weapons is contrary to the ethos of both conventions.

In situations of widespread public unrest and political or other uprisings governments unfortunately may choose to deploy riot control agents in a domestic setting. Although this is not in conflict with the principles of the CWC their use may still give rise to specific medical, legal and ethical challenges.

While riot control agents are designed to make remaining within the riot unpleasant and impractical, they are not expected to directly cause any injuries or deaths. As with all other agents, how they are used determines the concentration to which individuals are exposed. The ability to take evasive actions, such as leaving the area, to reduce exposure may also have an impact. It is recognised that individual determinants including general health and age will affect an individual’s response to chemical agent.

Release of chemical agents such as tear gas in a small enclosed space exposes individuals to concentrations far higher than those expected in normal deployment in riot situations, causing higher levels of serious morbidity and potentially death.

Misuse of riot control agents, leading to serious harms or deaths of demonstrators, exposing individuals excessively or using them for oppressing non-violent peaceful demonstrations, may lead to a breach of the human rights of the individuals concerned, in particular the right to life (article 3), the right to freedom of expression (article 19) and of peaceful assembly (article 20) of the Universal Declaration of Human Rights.

Governments, who authorize the stockpiling and use of such agents by their police and security forces, are urged to consider that there might be fatal results of their usage. Governments are required to ensure that they are used in a manner, which minimise their likelihood of causing serious morbidity and mortality.

RECOMMENDATION

The WMA recognises that the inappropriate use of riot control agents risks the lives of those targeted and exposes people around, amounting to a potential breach of human rights standards, in particular the right to life, the right to freedom of expression and of peaceful assembly as stated in the Universal Declaration of Human Rights.

In case of use of riot control agents, the WMA urges States to do so in a manner designed to minimise the risk of serious harm to individuals, and to prohibit its use in the presence of vulnerable populations, such as children, older people or pregnant women;

The WMA insists that riot control agents should never be used in enclosed spaces where chemical concentrations may reach dangerous levels, and where people cannot move away from areas with high concentrations of the agent;

The WMA insists that governments train police and other security forces in the safe and legal use of riot control agents, in order to minimise the risk of harm when they are deployed. This must include the rapid evacuation of any individual who is apparently suffering from a high level of exposure, not aiming people, and not using the agent excessively;

The WMA insists that States penalise individuals who misuse riot control agents and who deliberately endanger human life and safety by using the agents. Such misuse leading to serious physical harms or death of individuals should be investigated by independent experts.

The WMA calls for unimpeded and protected access of healthcare personnel to allow them to fulfil their duty of attending to the injured as set forth in the “WMA Declaration on the protection of healthcare workers in situations of violence”.

The WMA recommends that, because of the significant difficulties and risks to health and life associated with the use of such riot control agents, States should refrain from using them in any circumstances.

Adopted by the 200th WMA Council Session, Oslo, April 2015,
and adopted, with amendments by the 72nd WMA General Assembly (online), London, United Kingdom, October 2021 

 

PREAMBLE

Trade agreements are treaties between two or more countries which include provisions addressing trade in goods and/or services. Trade agreements are tools of globalization and typically seek to promote global wealth through trade liberalization. They can have significant implications for the social, commercial, political and ecological determinants of health as well as the delivery of health care. 

International trade contributes significantly to increases in national wealth which is a key factor in building strong health care systems.  

While trade agreements are designed to produce economic benefits and global wealth, it is fundamental to identify public health implications that may arise from these agreements.  

Negotiations should take into account broad impact to ensure that the right to health and to a healthy natural and social environment are well-prioritized. Trade agreements should be directed at contributing to global health and equity. 

Trade agreements may have the ability to promote the health and wellbeing of all people when they are well-designed to protect health and preserve the ability of governments to legislate, regulate and plan for health promotion, health care delivery and health equity. 

Recent trade agreement negotiations have sought to establish a new global governance framework for trade and have been unprecedented in their size, scope and secrecy. A lack of transparency and the selective sharing of information with a limited set of stakeholders are anti-democratic. 

There must be recognition of the importance of innovation sharing in public health. This is particularly important during health emergencies. Access to medicines and medical supplies is essential to address the major public health problems such as pandemics and trade agreements must not act as a barrier to that access. 

Investor-state dispute settlement (ISDS) provides a mechanism for investors to bring claims against governments and seek compensation, operating outside existing systems of accountability and transparency. ISDS in existing trade agreements has been used to challenge evidence-based public health measures including tobacco plain packaging. Inclusion of a broad ISDS mechanism could threaten public health actions designed to support evidence-based tobacco control, alcohol control, healthy and safe food consumption including regulation of obesogenic foods and beverages, access to medicines, health care services, environmental protection/climate change and occupational / environmental health protections. Efforts by industry to challenge domestic public health laws and regulation have targeted nations with limited access to legal resources and some of the world’s most vulnerable populations. 

Access to affordable medicines is critical to controlling the global burdens of communicable and non-communicable diseases. The World Trade Organization’s Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) established a set of common international rules governing the protection of intellectual property including the patenting of pharmaceuticals. TRIPS safeguards and flexibilities including compulsory licensing seek to ensure that patent protection does not supersede public health. 

The WMA Statement on Patenting Medical Procedures states that patenting of diagnostic, therapeutic and surgical techniques is unethical and “poses serious risks to the effective practice of medicine by potentially limiting the availability of new procedures to patients.” 

Trade agreements should not pose a new difficulty in accessing medicines, especially for developing countries and for the most vulnerable populations. 

There must be a fair balance established between the prices of medicines and the protection of intellectual property through patents. 

The WMA considers that patenting on medicines/vaccines must be regulated in accordance with the ethical principles and values of the medical profession in order to ensure effective and global action for public health and therefore recognizes that it may be necessary to temporarily waive patents in times of public health emergencies.  Moreover, to produce fast and comprehensive results, sustainable solutions for patent issues must be supplemented by the transfer of technology, knowledge, and manufacturing expertise, global investment in manufacturing sites, training of personnel, and quality control. 

The WMA Resolution on Medical Workforce states that the WMA has recognized the need for investment in medical education and has called on governments to “…allocate sufficient financial resources for the education, training, development, recruitment and retention of physicians to meet the medical needs of the entire population…” 

The WMA Declaration of Delhi on Health and Climate Change states that global climate change has had and will continue to have serious consequences for health and demands comprehensive action. 

The WMA Declaration on Fair Trade in Medical Products and Devices states that purchasing policies for medical goods should be fair and ethical, working conditions should be safe and modern slavery should be eradicated throughout supply chains. Health product manufacturers should establish a plan for continuity of supply of vital and life-sustaining products to avoid production shortages whenever possible. This plan should include establishing the necessary resiliency and redundancy in manufacturing capability to minimize disruptions of supplies. 

 

RECOMMENDATIONS 

 Therefore, the WMA calls on national governments and constituent member associations to: 

1.Call for transparency and openness in all trade agreement negotiations including public access to negotiating texts and meaningful opportunities for stakeholder engagement. 

2. Call for a proactive assessment of anticipated effects on health, human rights, and the environment for all trade agreements. 

3. Advocate for trade agreements that protect, promote and prioritize public health over commercial or political interests, and secure services in the public interest, especially those affecting individual and public health. This should include new modalities of health care provision including eHealth. 

4. Ensure that trade agreements do not have negative impacts on health systems, human resources for health and universal health coverage (UHC). Ensure trade agreements do not interfere with governments’ ability to protect and regulate health and health care, or to guarantee a right to health for all. Government action to protect and promote health should not be subject to challenge through an investor-state dispute settlement (ISDS) or similar mechanism.

5. Work to ensure that patents on medicines and vaccines are regulated in accordance with the principles of medical ethics, in order to protect public health in global emergency situations.  

6. Therefore, urge NMAs to promote the possibility of temporarily waiving patents on medicines and vaccines to protect public health in global emergency situations while ensuring fair compensation for the intellectual property of the patent holders, global investment in manufacturing sites, and knowledge transfer. Promote public health, equity, solidarity and social justice and protect countries and people who are weaker economically and health-wise, and therefore most vulnerable. 

7. Oppose any trade agreement provisions which would compromise access to health care services or medicines including but not limited to: 

  • Patenting (or patent enforcement) of diagnostic, therapeutic and surgical techniques; 
  • “Evergreening”, or patent protection for minor modifications of existing drugs; 
  • Patent linkage or other patent term adjustments that serve as a barrier to generic entry into the market; 
  • Data exclusivity for biologics; 
  • Any effort to undermine TRIPS safeguards or restrict TRIPS flexibilities including compulsory licensing; 
  • Limits on clinical trial data transparency. 

8. Oppose any trade agreement provision which would reduce public support for or facilitate commercialization of medical education. 

9. Oppose any trade agreement which would facilitate the inappropriate privatization of public services in areas such as conservation of natural environment, education, healthcare, and daily necessities such as energy and water. 

10. Ensure that trade agreements promote environmental protection and support efforts to reduce activities that cause climate change. 

 11. Ensure that trade agreements promote equity and human rights and include mechanisms for accountability following implementation. 

 

 

Adopted by the 65th World Medical Assembly, Durban, South Africa, October 2014
and rescinded and archived by the 75th WMA General Assembly, Helsinki, Finland, October 2024

Preamble

There are a number of ways in which the volume of harmful emissions can be reduced. These include encouraging fewer road traffic journeys, active transport for individuals undertaking relatively short journeys, the use of mass public transit in preference to individual vehicles, and alternative energy sources for vehicles, including electric and hybrid technologies. Where vehicle use is essential, means of reducing harmful emissions should be used.

Physicians around the world are aware of air pollution. It impacts the quality of life for hundreds of millions of people worldwide, causing both, a large burden of disease as well as economic losses and increased health care costs. According to WHO estimates, in 2012, urban outdoor air pollution was responsible for 3.7 million annual deaths, representing 6.7% of the total deaths (WHO, 2014).

Especially, diesel soot is acknowledged as a proven carcinogen (IARC, 07/2012). Furthermore, it has many other toxic effects, most prominently in the cardiovascular (Brook et al., 2010) and respiratory systems (ERS, 2010). Moreover, in the context of global warming, soot, along with methane, is identified as the second most important greenhouse driving force substance after CO2 (Kerr, 2013).

Despite the fact that new vehicles will have to comply with stricter emission standards which take into account most harmful ultra fine particles too, a high-polluting in-use fleet, including off-road vehicles such as construction engines and ships, will continue polluting for many more years.

Background

In many densely populated cities around the world, fine dust concentrations measurable as aerosols exceed up to 50 times the maximum WHO recommendation. High volumes of transport, power generated from coal, and pollution caused by construction machinery are among the contributing factors. People living and working near major (high density volume traffic) streets are most affected by pollutants.
For fighting the health risks mentioned above, there exist a variety of highly efficient and reliable filter systems on the market (Best Available Technology (BAT) filters[1]). They are applicable to all internal combustion engines and they reduce even most harmful ultra-fine particles by a factor of over one hundred.
As soon as 90% of heavy duty vehicles, both, new and upgraded ones, satisfy this standard, health problems attributable to emissions of heavy duty traffic will be greatly reduced, and no further tightening of emission standards will be possible or even needed at all because of an almost total elimination of the pollutant as such.

In a variety of countries on different continents and under varying conditions retrofit or upgrading programs have been successfully performed. The UN’s Working Party on Pollution Prevention and Energy in Geneva has just proposed a technical standard for regulation in their member states, which will be applicable worldwide.

The WMA supports these efforts and calls on policy makers in all countries, especially in urban regions, to introduce regulatory restrictions of access for vehicles without filter, and/or to provide financial assistance to support the retrofitting of in-use vehicles.

Recommendations

The WMA therefore recommends that all NMAs should encourage their respective governments to:

  1. Introduce BAT standards for all new diesel vehicles (on road and off-road)
  2. Incentivise retrofitting with BAT filters for all in-use engines
  3. Monitor and limit the concentration of nanosize soot particles in the urban breathing air
  4. Conduct epidemiological studies detecting and differentiating the health effects of ultrafine particles
  5. Build professional and public awareness of the importance of diesel soot and the existing methods of eliminating the particles
  6. Contribute to developing strategies to protect people from soot particles in aircraft passenger cabins, trains, homes and in the general environment. These strategies should include plans to develop and increase use of public transportation systems.

 

Abbreviations:

EPA: Environmental Protection Agency (US)

ERS: European Respiratory Society

IARC: International Agency for Research of Cancer

BAT Standards: Emission standards for passenger cars, heavy-duty vehicles and off-road machinery, based on count of ultrafine particles rather than mass and aimed at the protection of human health from the most hazardous soot particles, the lung and even cell membrane penetrating ultra-fines.

References:

  • Brook, Robert D. et al. (2010): AHA Scientific Statement: Particulate Matter Air Pollution and Cardiovascular Disease. An Update to the Scientific Statement from the American Heart Association. Circulation 121: 2331-2378.
  • ERS (2010): The ERS report on air pollution and public health. European Respiratory Society, Lausanne, Switzerland. ISBN: 978-1-84984-008-8
  • IARC (2012): “IARC: Diesel Engine Exhaust Carcinogenic”. Press Release No. 213. http://www.iarc.fr/en/media-centre/pr/2012/pdfs/pr213_E.pdf .
    (access: 14/02/14)
  • Kerr, Richard R. (2013): “Soot is Warming the World Even More Than Thought”. In: Science 339(6118), p. 382.
  • WHO (2014): “Burden of disease from Ambient Air Pollution for 2012.” http://www.who.int/phe/health_topics/outdoorair/databases/AAP_BoD_results_March2014.pdf?ua=1   (access: 26/08/14)

[1] Euro 6/VI, US/EPA/CARB, Chinese and equivalent standards.

Adopted by the 65th WMA General Assembly, Durban, South Africa, October 2014
and revised by the 70th WMA General Assembly, Tbilisi, Georgia, October 2019

 

PREAMBLE 

In many countries, a substantial number of prisoners are held in solitary confinement. Solitary confinement is a form of confinement used in detention settings where individuals are separated from the general detained population and held alone in a separate cell or room for upwards of 22 hours a day. Jurisdictions may use a range of different terms to refer to the process (such as segregation, separation, isolation or removal from association) and the conditions and environment can vary from place to place. However, it may be defined or implemented, solitary confinement is characterised by complete social isolation; a lack of meaningful contact; and reduced activity and environmental stimuli. Some countries have strict provisions on how long and how often prisoners can be kept in solitary confinement, but many countries lack clear rules on this.

Solitary confinement can be distinguished from other brief interventions when individuals must be separated as an immediate response to violent or disruptive behaviour or where a person must be isolated to protect themselves or others. These interventions should take place in a non-solitary confinement environment.

The reasons for the use of solitary confinement vary in different jurisdictions and it can be used at various stages of the criminal justice process. It may be used as a disciplinary measure for the maintenance of order or security; as an administrative measure, for the purposes of investigation or questioning; as a preventive measure against future harm (either to the individual or to others); or it may be the consequence of a restrictive regime that limits contact with others. It can be imposed for hours to days or even years. 

Medical impacts of solitary confinement

People react to isolation in different ways. For a significant number of prisoners, solitary confinement has been documented to cause serious psychological, psychiatric, and sometimes physiological effects. These include insomnia, confusion, hallucinations, psychosis, and aggravation of pre-existing health problems. Solitary confinement is also associated with a high rate of suicidal behaviour. Negative health effects can occur after only a few days and may in some cases persist when isolation ends.

Certain populations are particularly vulnerable to the negative health effects of solitary confinement. Persons with psychotic disorders, major depression, or post-traumatic stress disorder or people with severe personality disorders may find isolation unbearable and suffer considerable health harms. Solitary confinement may complicate treating such individuals and their associated health problems successfully later in the prison environment or when they are released back into the community. Prisoners with physical disabilities or other medical conditions often have their conditions aggravated, not only as a result of the physical conditions of isolation, but also as the particular health requirements linked to their disability or condition are often not accommodated.

For children and young people, who are in the crucial stages of developing socially, psychologically, and neurologically, there are serious risks of solitary confinement causing long-term mental and physical harm. A growing international consensus about the harms of solitary confinement on children and young people has resulted in some jurisdictions abolishing the practice completely.

International norms on solitary confinement

The increasing documentation on the harmful impact of solitary confinement on the health of prisoners led to the development of a range of international norms and recommendations seeking to mitigate the use and the harmful effect of solitary confinement.

The United Nations Standard Minimum Rules for the Treatment of Prisoners (SMR) were first adopted in 1957, and revised in 2015 as the Nelson Mandela Rules unanimously adopted by the United Nations Assembly. The SMR constitute the key international framework for the treatment of prisoners.

Other international standards and recommendations, such as the United Nations Rules for the Treatment of Women Prisoners and Non-Custodial Sanctions for Women Offenders (the Bangkok Rules), the United Nations Rules for the Protection of Juveniles Deprived of their Liberty and the observations of the Special Rapporteur on Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment, support and complete the Nelson Mandela Rules.

The misuse of solitary confinement can include indefinite or prolonged solitary confinement (defined as a period of solitary confinement in excess of 15 days), but can also include corporal or collective punishment, the reduction of a prisoner’s diet or drinking water, or the placement of a prisoner in a dark or constantly lit cell. Misuse of solitary confinement in these ways can constitute a form of torture or ill-treatment and as such must be prohibited in line with international human rights law and medical ethics.

The WMA and its members reiterate their firm and long-standing position condemning any forms of torture and other cruel, inhuman or degrading treatment or punishment and reaffirm the basic principle that doctors should never participate in or condone torture or other cruel, inhuman or degrading treatment.

 

RECOMMENDATIONS

1. Given the harmful impact of solitary confinement, which can on occasion result in a form of torture or ill-treatment, the WMA and its members call for the implementation of the Nelson Mandela Rules and other associated international standards and recommendations, with a view to protect the human rights and the dignity of the prisoners.

2. The WMA and its members emphasize in particular the respect of the following principles:

  • In light of the serious consequences solitary confinement can have on physical and mental health (including an increased risk of suicide or self-harm), it should be imposed only in exceptional cases as a last resort and subject to independent review, and for the shortest period of time possible. The authority imposing the solitary confinement must be acting in line with clear rules and regulations as to its use.
  • All decisions on solitary confinement must be transparent and regulated by law. The use of solitary confinement should be time-limited by law. The detainee should be informed of the duration of the isolation, and the period of duration should be determined before the measure takes place. Prisoners subject to solitary confinement should have a right of appeal.
  • Solitary confinement should not exceed a time period of 15 consecutive days. Releasing the prisoner from solitary confinement for a very limited period of time, with the intention that the individual will be placed in solitary confinement immediately again to get around the rules on length of stay must also be prohibited.

Prohibitions of the use of solitary confinement

3. The indefinite or prolonged solitary confinement should be prohibited as amounting to torture or other cruel, inhuman or degrading treatment or punishment [1].

4. Solitary confinement should be prohibited for children and young people (as defined by domestic law), pregnant women, women up to six months post-partum, women with infants and breastfeeding mothers as well as for prisoners with mental health problems given that isolation often results in severe exacerbation of pre-existing mental health conditions.

5. The use of solitary confinement should be prohibited in the case of prisoners with physical disabilities or other medical conditions where their conditions would be exacerbated by such measures.

6. Where children and young people must be separated, in order to ensure their safety or the safety of others, this should be carried out in a non-solitary confinement setting with adequate resources to meet their needs, including ensuring regular human contact and purposeful activity.

Conditions of solitary confinement

7. The human dignity of prisoners confined in isolation must always be respected.

8. Prisoners in isolation should be allowed a reasonable amount of meaningful regular human contact, activity, and environmental stimuli, including daily outside exercise. As with all prisoners, they must not be subjected to extreme physically and/or mentally taxing conditions.

9. Prisoners who have been in solitary confinement should have an adjustment period, including a medical examination, before they are released from prison. This must never extend their period of incarceration.

Role of physician

10. The physician’s role is to protect, advocate for, and improve prisoners’ physical and mental health, not to inflict punishment. Therefore, physicians should never participate in any part of the decision-making process resulting in solitary confinement, which includes declaring an individual as “fit” to withstand solitary confinement or participating in any way in its administration. This does not prevent physicians from carrying out regular visits to those in solitary confinement to assess health and provide care and treatment where necessary, or from raising concerns where they identify a deterioration in an individual’s health.

11. The provision of medical care should take place upon medical need or the request of the prisoner. Physicians should be guaranteed daily access to prisoners in solitary confinement, upon their own initiative. More frequent access should be granted if physicians deem this to be necessary.

12. Physicians working in prisons must be able to practice with complete clinical independence from the prison administration. In order to maintain that independence, physicians working in prisons should be employed and managed by a body separate from the prison or criminal justice system.

13. Physicians should only provide drugs or treatment that are medically necessary and should never prescribe drugs or treatment with the intention of enabling a longer period of solitary confinement.

14. Healthcare should always be provided in a setting that respects the privacy and dignity of prisoners. Physicians working in the prison setting are bound by the same codes and principles of medical ethics as they would be in any other setting.

15. Physicians should report any concerns about the impact solitary confinement is having on the health and wellbeing of an individual prisoner to those responsible for reviewing solitary confinement decisions. If necessary, they should make a clear recommendation that the person be removed from solitary confinement, and this recommendation should be respected and acted upon by the prison authorities.

16. Physicians have a duty to consider the conditions in solitary confinement and to raise concerns with the authorities if they believe that they are unacceptable or might amount to inhumane or degrading treatment. There should be clear mechanisms in place in each system to allow physicians to report such concerns.

 

Reference

[1] Rule 43 SMR

Adopted by the 64th General Assembly, Fortaleza, Brazil, October 2013 and
reaffirmed with minor revisions by the 224th WMA Council, Kigali, Rwanda, October 2023

 

PREAMBLE

The WMA Resolution on Physician Participation in Capital Punishment states that it is unethical for physicians to take part in capital punishment, and the WMA Declaration of Geneva obliges physicians to maintain the utmost respect for human life.

The WMA acknowledges that the views prevalent in the countries of some of its members prevent all members from unconditionally opposing the death penalty.

The WMA therefore supports the suspension of the use of the death penalty through a global moratorium.

The WMA has long recognized that it cannot hold its constituent members responsible for the actions and policies of their respective governments.

 

RECOMMENDATION

The World Medical Association supports the United Nations moratorium on the use of the death penalty.

Adopted by the 64th General Assembly, Fortaleza, Brazil, October 2013 and
revised by the 74th WMA General Assembly, Kigali, Rwanda, October 2023

 

PREAMBLE

Individuals who identify as LGBTQIA+ (Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, Asexual, and other identities beyond these) represent a broad and fluid spectrum of natural sexual orientations, gender identities, gender expressions, and sex characteristics. While LGBTQIA+ people may share common cultural and social experiences and shared goals of justice and equity in the face of detrimental, discriminatory treatment and even violence, these are diverse communities facing distinct challenges and with specific needs in healthcare and beyond.

This statement is specifically focused on lesbian, gay, and bisexual people.

Healthcare professionals encounter many aspects of human diversity when providing care, including different natural variations of human sexuality.

A large body of scientific research indicates that being lesbian, gay, or bisexual constitute natural variations of human sexuality without any intrinsically harmful health effects. They do not constitute a disorder or illness that requires treatment or cure and any efforts to do so are contrary to the ethical practice of medicine.

Homosexuality and bisexuality are consequently not included in the World Health Organization’s (WHO) International Classification of Diseases (ICD 11).

However, direct and indirect discrimination, both interpersonally and at the institutional level, anti-homosexual or anti-bisexual legislation and human rights violations, stigmatisation, criminalisation of same-sex partnerships, peer rejection, and bullying continue to have a serious impact upon the psychological and physical health of lesbian, gay, or bisexual people. These negative experiences are perpetuated by a lack of education in society on the different natural variations of human sexuality. They lead to poorer health outcomes, including higher prevalence rates of depression, anxiety disorders, substance misuse, and suicidal ideations and attempts. As a result, the suicide rate among lesbian, gay, or bisexual adolescents and young adults significantly higher than that of their heterosexual peers.

These negative outcomes can be exacerbated by other intersectional factors, including but not limited to national origin, race, ethnicity, gender, age, religion, gender identity, socioeconomic status, or disabilities.

In addition, false and baseless pathologisation of lesbian, gay, or bisexual identities leaves such individuals at risk of being coerced into so-called “conversion” or “reparative” procedures. These harmful and unethical practices, also sometimes referred to as sexual orientation and gender identity change efforts (SOGICE), are intended to suppress or change a person’s natural sexual orientation or gender identity. These methods have no medical indication, lack any evidence of effectiveness, and represent a serious threat to the health and human rights of those subjected to these practices. They can lead to anxiety, depression, low self-esteem, substance abuse, problems with intimacy, and suicide.

Negative experiences in healthcare may affect the patient-physician relationship, leading lesbian, gay, and bisexual individuals to avoid accessing care where it is available. They may also withhold their sexual orientation from physicians due to the resulting lack of confidence that they will receive the appropriate treatment and concerns about the safety and confidentiality of their healthcare environment. Without this information, it may be more challenging for physicians to provide targeted care that takes into account the specific health needs of lesbian, gay, or bisexual patients.

Lesbian, gay, or bisexual physicians, medical students, and other health professionals also face discrimination, disadvantages, marginalisation and bullying in the workplace, in schools, in professional organisations, and beyond. Harmful working and learning environments can lead to stress and burnout, especially among marginalised individuals.

 

RECOMMENDATIONS

  1. The WMA strongly asserts that being lesbian, gay, or bisexual does not represent a disease, but rather natural variations within the range of human sexuality.
  2. The WMA condemns all forms of stigmatisation, criminalisation of and discrimination against people based on their sexual orientation.
  3. The WMA asserts that psychiatric or psychotherapeutic support, when needed, must not focus upon the variations of sexuality itself, but rather upon conflicts which arise between those variations and religious, social and internalised norms and prejudices, as well as the health needs of the individual patient.
  4. The WMA unequivocally condemns so-called “conversion” or “reparative” methods. These constitute violations of human rights and are unjustifiable practices that should be denounced and subject to sanctions and penalties. It is unethical for physicians to participate during any step of any such procedures.
  1. The WMA calls upon all physicians to:
    • classify physical and psychological diseases on the basis of clinically relevant symptoms according to ICD 11 criteria regardless of sexual orientation, and to provide quality, evidence-based care in accordance with internationally recognised treatments and protocols and in keeping with the principles set forth in the WMA International Code of Medical Ethics;
    • provide a safe, respectful, and inclusive healthcare setting for lesbian, gay, and bisexual patients;
    • foster safe, respectful, and inclusive work and learning environments for lesbian, gay, and bisexual physicians, medical students, and other health professionals;
    • engage in continuing education and professional development to better understand the specific health needs of lesbian, gay, and bisexual patients and the benefits of certain treatments;
    • where appropriate, involve patients’ same-sex partners and same-sex parents in healthcare discussions in keeping with the patient’s preferences, respecting their consent, and with due regard for patient confidentiality;
    • speak out against legislation and practices violating the human rights of lesbian, gay, and bisexual people, which may also negatively impact the healthcare system at large;
    • reject and refuse to participate in any step of so-called “conversion” or “reparative” methods.
  1. The WMA calls upon constituent members and professional associations to:
    • advocate for safe and inclusive working and learning environments for lesbian, gay, and bisexual physicians, medical students, and other health professionals;
    • establish and enforce non-discriminatory policies in keeping with the WMA Statement on Non-Discrimination in Professional Membership and Activities of Physicians;
    • create guidelines for physicians outlining the specific physical and mental health challenges facing lesbian, gay, and bisexual patients, where appropriate;
    • Where possible, promote changes to medical education, specialty training and CME/CPD curricula to create sensitivity and awareness of the specific health needs of lesbian, gay, and bisexual patients;
    • establish channels for lesbian, gay, and bisexual physicians to report incidents of discrimination or bias against themselves or lesbian, gay, or bisexual patients;
    • in environments where confidentiality and patient safety are guaranteed and data cannot be abused, encourage voluntary data collection in the clinical setting and regular reporting on the health outcomes of lesbian, gay, and bisexual patient groups, while also taking intersectionality into account, to ensure and further improve targeted and appropriate healthcare provision;
    • actively condemn so-called “conversion” or “reparative” methods as unethical.
  1. The WMA calls upon governments to:
    • reject and repeal anti-homosexual or anti-bisexual legislation;
    • condemn and ban so-called “conversion” or “reparative” methods;
    • promote policies that counteract health-related and other inequities caused by overt and implicit discrimination against lesbian, gay, and bisexual people;
    • encourage education from an early age on diverse natural variations of human sexuality to increase acceptance and with the ultimate aim of promoting better physical and mental health for all individuals.

Adopted by the 64th General Assembly, Fortaleza, Brazil, October 2013 and
reaffirmed with minor revisions by the 224th WMA Council, Kigali, Rwanda, October 2023

 

PREAMBLE

The World Medical Association notes with grave concern the continued use of torture in many countries throughout the world.

The WMA reaffirms its total condemnation of all form of torture, and other cruel, inhuman or degrading treatment or punishment, as defined by the United Nations Convention Against Torture (CAT, 1984). Torture is one of the gravest violations of international human rights law and has devastating consequences for victims, their families and society as a whole. Torture causes severe physical and mental injuries and is a crime absolutely prohibited under international law.

The WMA reaffirms its policies adopted previously, namely:

The medical evaluation is an essential factor in pursuing the documentation of torture and the reparation of victims of torture. Physicians have a critical role to play in gathering information about torture, documenting evidence of torture for legal purposes, as well as supporting and rehabilitating victims.

The WMA recognizes the adoption, in December 2012, by the UN Committee Against Torture of the General Comment on the Implementation of article 14 of Convention against Torture relating to the right to reparation of victims of torture. The General Comment outlines the right of rehabilitation as an obligation on States and specifies the scope of these services. The WMA welcomes in particular:

  • The obligation of State parties to adopt a “long-term and integrated approach and ensure that specialized services for the victim of torture or ill treatment are available, appropriate and promptly accessible”, without making access to these services dependent on the victim pursuing judicial remedies [1].
  • The recognition of the right of victims to choose a rehabilitation service provider, be it a State institution, or a non-State service provider, which is funded by the State.
  • The recognition that State parties should provide torture victims with access to rehabilitation programs as soon as possible following an assessment by qualified independent healthcare professionals.
  • The references to measures aimed at protecting health and legal professionals who assist torture victims, developing specific training on the Istanbul Protocol for health professionals, and promoting the observance of international standards and codes of conduct by public servants, including medical, psychological and social service personnel [2].

The WMA notes that since the adoption of the General Comment on the Implementation of article 14, important developments have taken place in the practice of rehabilitation and in monitoring State compliance with their obligations:

 

RECOMMENDATIONS

  1. The WMA emphasizes the vital function of reparation for victims of torture and their families in rebuilding their lives and achieve redress and the important role of physicians in rehabilitation.
  2. The WMA encourages its member associations to work with relevant agencies – governmental and non-governmental – acting for the reparation of victims of torture, in particular in the areas of documentation and rehabilitation, as well as prevention, and to use the revised Istanbul Protocol and the global rehabilitations standards in doing so.
  3. The WMA encourages its members to support agencies that are under threat of – or subjected to – reprisals from state parties due to their involvement in the documentation of torture, rehabilitation and reparation of torture victims.
  4. The WMA calls on its members to use their medical experience to support torture victims in accordance with article 14 of the UN Convention against Torture, including by helping them to become active agents in their own rehabilitation process through survivor explicit programs.
  5. The WMA calls on its member associations to support and facilitate data collection at the national level, using established indicators for the right to rehabilitation, to monitor the implementation of the State’s obligation to provide rehabilitation services.

 

[1] Paragraph 13 of the General Comment
[2] Paragraph 18 of the General Comment
[3] Global Impact Data – IRCT

Adopted by the 64th WMA General Assembly, Fortaleza, Brazil, October 2013 and
reaffirmed with minor revisions by the 224th WMA Council, Kigali, Rwanda, October 2023

 

PREAMBLE

According to WHO Fungal Priority Pathogens List (WHO FPPL), fungal pathogens are a major threat to public health as they are becoming increasingly common and resistant to treatment. Moreover, emerging evidence suggest that global warming and the rise in international travel and trade are contributing to the worldwide expansion of fungal diseases, in both incidence and geographic range.

Invasive and chronic fungal diseases lead to estimated annual morbidity rates that are similar to those caused by commonly recognized global health concerns such as malaria and tuberculosis. In addition to death, these fungal diseases commonly lead to chronic ill health, including blindness with keratitis, respiratory distress with allergic bronchopulmonary aspergillosis (ABPA), severe asthma with fungal sensitisation (SAFS) and chronic pulmonary aspergillosis (CPA), weight loss and nutritional deficiency with oesophageal candidiasis and CPA, and inability to engage in healthy sexual activity with vulvovaginal candidiasis.

Serious fungal diseases are often opportunistic, occurring as a consequence of other conditions that suppress the immune system, such as asthma, AIDS, cancer, post–transplant immunosuppressive drugs and corticosteroid therapies.

Even though many fungal diseases can be treated relatively simply, in many cases, these diseases go untreated. Fungal infections alone are often not distinctive enough to allow a clinical diagnosis, and as cultures are frequently falsely negative, missed diagnoses are common. In addition, a relatively narrow diagnostic window to cure the patient is frequently missed, resulting in prolonged expensive hospital stays, often with a fatal outcome. Lastly, effective medicine to treat fungal infections are often not available when and where they are needed.

Despite the increasing concern, WHO emphasizes the inadequate attention and resources allocated to fungal infections, resulting in a lack of reliable data regarding the distribution of fungal diseases and patterns of antifungal resistance. Consequently, “the exact burden of fungal diseases and antifungal resistance, are unknown, and the response is therefore undermined” [1].

RECOMMENDATIONS

  1. In line with WHO Fungal Priority Pathogens List (WHO FPPL), the WMA recommends strategies aimed at generating evidence and improving response to fungal pathogens including preventing the development of antifungal drug resistance, and in particular urges governments as well as other health stakeholders concerned to:
    • ensure that both diagnostic tests and antifungal therapies are available for their populations;
    • depending on the prevalence of fungal diseases and their underlying conditions, guarantee the provision of specific antigen testing or microscopy and culture;
    • ensure the availability of these tests, and of health personnel educated to administer and interpret the tests, in all countries where systemic fungal infections occur;
    • consider developing diagnostic centre of excellence with a sufficient health personnel with adequate education on fungal infections diagnosis;
    • provide monitoring for antifungal toxicities;
    • support medical associations in developing adequate medical courses to ensure an effective diagnostic approach of fungal infections.
  1. The WMA encourages its constituent members to undertake and support epidemiologic studies on the burden of fungal disease in their country and to inform the national government of the results.

 

[1] WHO releases first-ever list of health-threatening fungi.

Adopted by the 63rd WMA General Assembly, Bangkok, Thailand, October 2012
and reaffirmed by the 212th WMA Council Session, Santiago, Chile, April 2019

 

PREAMBLE

Vaccination use to prevent against disease was first done successfully by Jenner in 1796 when he used cowpox material for vaccination against smallpox.  Since then, vaccination and immunisation have been acknowledged as an effective preventive strategy for several communicable diseases and are now being developed for the control of some non-communicable diseases.

Vaccine development and administration are some of the most significant interventions to influence global health in modern times.  It is estimated that immunisation currently prevents approximately 2.5 million deaths every year, saving lives from diseases such as diphtheria, tetanus, whooping cough (pertussis) and measles. Approximately 109 million children under the age of one are fully vaccinated with the diphtheria-tetanus-pertussis (DTP3) vaccine alone.

Mostly the ultimate goal of immunisation is the total eradication of a communicable disease.  This was achieved for smallpox in 1980 and there is a realistic goal for the eradication of polio within the next few years.

The Global Immunisation Vision Strategy (GIVS) 2006-2015 was developed by the WHO and UNICEF in the hope of reaching target populations who currently do not have immunisation services or who do not have an adequate level of coverage.

The four strategies promoted in this vision are:

  • Protecting more people in a changing world
  • Introducing new vaccines and technologies
  • Integrating immunisation, other linked health interventions and
  • Surveillance in the health systems context
  • Immunizing in the context of global interdependence [1]

Vaccine research is constantly revealing new possibilities to protect populations from serious health threats.  Additionally, new strains of diseases emerge requiring the adaptation of vaccines in order to offer protection.

The process of immunisation requires an environment that is resourced with appropriate materials and health workers to ensure the safe and effective administration of vaccines.  Administration of vaccines often requires injections, and safety procedures for injections must always be followed.

Immunisation schedules can vary according to the type of vaccine, with some requiring multiple administrations to be effective.  It is vitally important that the full schedule is followed otherwise the effectiveness of the vaccine may be compromised.

The benefits of immunisation have had a profound effect on populations, not only in terms of preventing ill health but also in permitting resources previously required to treat the diseases to be redirected to other health priorities.  Healthier populations are economically beneficial and can contribute more to society.

Reducing child mortality is the fourth of the United Nation’s Millennium Development Goals, with immunisation of children having a significant impact on mortality rates on children aged under five. According to the WHO, there are still more than 19 million children who have not received the DTP3 vaccine. In addition, basic health care services for maternal health with qualified health care personnel must be established.

Immunisation of adults for diseases such as influenza and pneumococcal infections has been shown to be effective, not only in decreasing the number of cases amongst those that have received immunisation but also in decreasing the disease burden in society.

The medical profession denounce any claims that are unfounded and inaccurate with respect to the possible dangers of vaccine administration.  Claims such as these have resulted in diminished immunisation rates in some countries.  The result is that the incidences of the diseases to be prevented have increased with serious consequences for a number of persons.

Countries differ in immunisation priorities, with the prevalence and risk of diseases varying among populations. Not all countries have the same coverage rates, nor do they have the resources to acquire, coordinate, distribute or effectively administer vaccines to their populations, often relying on non-governmental organizations to support immunisation programmes.  These organizations in turn often rely on external funding that may not be secure.  In times of global financial crisis, funding for such programmes is under considerable pressure.

The risk of health complications from vaccine-preventable diseases is greatest in those who experience barriers in accessing immunisation services. These barriers could be cost, location, lack of awareness of immunisation services and their health benefits or other limiting factors.

Those with chronic diseases, underlying health issues or other risk factors such as age are at particular risk of major complications due to vaccine-preventable diseases and therefore should be targeted to ensure adequate immunisation.

Supply chains can be difficult to secure, particularly in countries that lack coordination or support of their immunisation programmes.  Securing the appropriate resources, such as qualified health professionals, equipment and administrative support can present significant challenges.

Data collection on vaccine administration rates, side effects of vaccines and disease surveillance can often be difficult to achieve, particularly in isolated and under-resourced areas. Nevertheless, reporting incidents and monitoring disease spread are vital tools in combating global health threats.

 

RECOMMENDATIONS

The WMA supports the recommendations of the Global Immunisation Vision Strategy (GIVS) 2006-2015, and calls on the international community to:

  • Encourage governments to commit resources to immunisation programmes targeted to meet country specific needs.
  • Recognise the importance of vaccination/immunisation through the continued support and adoption of measures to achieve global vaccination targets and to meet the Millennium Development Goals, especially four (reduce child mortality), five (improve maternal health) and six (combat HIV/AIDS, malaria and other diseases).
  • Recognise the global responsibility of immunisation against preventable diseases and support work in countries that have difficulties in meeting the 2012 targets in the Global Polio Eradication Initiative [2].
  • Support national governments with vulnerable populations at risk of vaccine-preventable diseases, and the local agencies that work to deliver immunisation services and to work with them to alleviate retrictions in accessing services.
  • Support vaccine research and development and ensure commitment through the adequate funding of vital vaccine research.
  • Promote vaccination and the benefits of immunisation, particularly targeting those at-risk and those who are difficult to reach. Comply with monitoring activities undertaken by WHO and other health authorities.Promote high standards in the research, development and administration of vaccines to ensure patient safety. Vaccines need to be thoroughly tested before implemented on a large scale and subsequently monitored in order to identify possible complications and untoward side effects. In order to be successful, immunisation programmes need public trust which depends on safety.

In delivering vaccination programmes, the WMA recommends that:

  • The full immunisation schedule is delivered to provide optimum coverage.  Where possible, the schedule should be managed and monitored by suitably trained individuals to ensure consistent delivery and prompt appropriate management of adverse reactions to vaccines.
  • Strategies are employed to reach populations that may be isolated because of location, race, religion, economic status, social marginalization, gender and/or age.
  • Ensure that qualified health professionals receive comprehensive training to safely deliver vaccinations and immunisations, and that vaccination/immunisations are targeted to those whose need is greatest.
  • Educate people on the benefits of immunisation and how to access immunisation services.
  • Maintain accurate medical records to ensure that valid data on vaccine administration and coverage rates are available, enabling immunisation policies to be based upon sound and reliable evidence.
  • Healthcare professionals should be seen as a priority population for the receipt of immunisation services due to their exposure to patients and to diseases.

The WMA calls upon its members to advocate the following:

  • To increase awareness of national immunisation schedules and of their own (and their dependents) personal immunisation history.
  • To work with national and local governments to ensure that immunisation programmes are resourced and implemented.
  • To ensure that health personnel delivering vaccines and immunisation services receive proper education and training.
  • To promote the evidence base and increase awareness about the benefits of immunisation amongst physicians and the public.

 

References

[1] World Health Organization and United Nations Children’s Fund. Global Immunisation Vision and Strategy, 2006-2015. Geneva, Switzerland: World Health Organization and United Nations Children’s Fund; 2005.  Available at: http://www.who.int/immunisation/givs/related_docs/en/index.html

[2] World Health Organization. Global Polio Eradication Initiative: Strategic Plan 2010-2012. Geneva, Switzerland: World Health Organization; 2010. Available at: http://polioeradication.org/who-we-are/strategy/

Adopted by the 67th WMA General Assembly, Taipei, Taiwan, October 2016
and revised by the 73rd WMA General Assembly, Berlin, Germany, October 2022

PREAMBLE

Occupational and environmental health and safety (OEHS) is an integral part of public health, and the primary health care (PHC) system in particular, since it is often the first level of contact of individuals, the family and the community with a health system, bringing health care as close as possible to where people live and work.

Workers represent at least half of the world’s population and are the backbone of many economies, but many may have inadequate access to occupational and environmental health services and do not operate in a safe working environment.

The International Labour Organization (ILO) defines decent work as opportunities for work that are productive and deliver fair income with dignity, equality, and within safe working conditions. Despite the fact that the right to decent work is recognized in the Universal Declaration of Human Rights, every 15 seconds, a worker dies from a work-related accident or disease , resulting in an annual 4% loss in global GDP.

Despite this, the proportion of work accidents and occupational diseases that are recorded and reported worldwide is incredibly small. It is estimated that less than 1% of occupational diseases are recorded.

Additionally, as many workers face greater pressures to meet the demands of working life, many of them are at risk to develop work-related stress which may occur when the demands of the job do not match or exceed the capabilities, resources or needs of the worker or when the knowledge or abilities of an individual worker or group to cope are not matched with the expectations of the organizational culture of an enterprise. High-level of stress can result in health impairments such as burnout, depression, anxiety, cardiovascular disease or even suicide.

Recently and even more due to the COVID-19 pandemic, the world has witnessed an increased number of employees working outside the employer’s premises using digital information and communication technologies either full-time or part-time. Despite some positive aspects, there are risks associated with this work arrangement as it isolates employees, particularly individuals living alone and can result in increased levels of stress and anxiety. Extended working hours and employee availability in addition to diminished boundaries between personal and professional life may impact work-life balance. A healthy digital working environment needs to be in place to ensure employee health and safety.

The United Nations Development Programme’s Sustainable Development Goals 3, 5, 8 and 13 call for action in health promotion for all people of all ages, gender equality, decent work and management of the impact of climate change; OEHS is well positioned to maintain physical, mental and social well-being for all workers, that will result in poverty reduction, sustainable development and saving millions of lives every year.

Physicians have a critical role in preventing, diagnosing, monitoring, treating and reporting work accidents and occupational diseases. In addition, physicians should promote equal, decent and inclusive work environments for all regardless of age, gender, ethnic origin, nationality, religion, political affiliation, race, sexual orientation, or the presence of a disability.

Despite many governments and employers’ and workers’ organizations placing greater emphasis on the prevention of occupational diseases. prevention is not receiving the priority warranted by the scale and severity of the occupational disease epidemic.

Physicians and medical associations can contribute to the identification of problems, development of national reporting systems, and formulation of relevant policies in the field of OEHS.

Unsatisfactory and unsafe working conditions play a significant role in the development of occupational diseases and injuries, which are subsequently causes of mortality in the working population.

 

RECOMMENDATIONS

  1. Physicians should play a pivotal role in the development of a workforce that is educated in and raise workplace awareness about the social determinants of health.
  2. The field of occupational and environmental health and safety (OEHS) should be accorded the necessary importance in both graduate and post-graduate medical studies
  3. Physicians must cooperate with the healthcare and occupational authorities to promote health and safety in the workplace.
  4. All workers should have access to risk based OEHS services from the first day of work and extending beyond the last day at work in order to account for occupational diseases with a long latency period.  Service content should be standardized and the role of physicians in the planning and implementation of OEHS systems that are essentially preventive/protective must be recognized.
  5. WMA Constituent members should act proactively and encourage the expansion of the scope of OEHS services, in order to prevent and reduce occupational diseases, and injuries, reproductive health issues and protect the environment. They should also promote workplace gender equality and encourage improvement of recording and reporting systems for OEHS-related metrics. They should also focus on workforce capacity building, teaching and training, and collaborative research.
  6. WMA Constituent members, together with governments, should take an active role, where appropriate, in the formulation and development of national systems that facilitate OEHS prevention, and the recording and reporting of occupational diseases and incidents in their respective countries.
  7. Physicians who are evaluating workers’ compensation patients should be experienced in occupational and environmental medicine. When a relationship between the diagnosis and occupational and environmental exposures is established, the physician should report it through the appropriate reporting system.
  8. Occupational diseases and injuries are often addressed in the context of insurance and compensation. Where these mechanisms are not in place, WMA Constituent members should advocate for the protection of workers by means of insurance or social security.
  9. When rendering services for an employer, physicians should advocate that employers fulfil the minimum requirements set in the International Labour Organization’s (ILO) occupational standards, especially when such requirements are not set by national legislation.
  10. Employers should provide a safe working environment, recognising and addressing the impact of adverse working conditions on individuals and society.
  11. Employers should consider promoting and offering essential vaccines to employees.
  12. WMA Constituent members should consider forming an internal body for addressing the problems of physicians working in OEHS and encourage them to contribute to research and related scientific studies.
  13. Governments should collaborate in setting up an international system to assess occupational hazards and develop strategies to protect the health of workers.
  14. Governments should establish legislative frameworks that protect the rights and health of workers, including reproductive health and health effects of work at home.
  15. Governments and NMAs must promote the development of training, information and research programs in occupational health to their members.

 

Adopted by the 63rd WMA General Assembly, Bangkok, Thailand, October 2012 and
revised by the 74th WMA General Assembly, Kigali, Rwanda, October 2023

 

PREAMBLE

Electronic cigarettes (e-cigarettes) and other electronic nicotine delivery systems (ENDS) are products designed to deliver nicotine to a user in the form of an aerosol. These products are usually composed of a mouthpiece, a rechargeable battery-operated heating element, a replaceable cartridge that contains liquid nicotine and/or other chemicals, and an atomizer that, when heated, turns the contents of the cartridge into an aerosol. This aerosol is then inhaled by the user and exhaled. These products are often made to look like other tobacco-derived products like cigarettes, cigars, pipes, toys and electronics that appeal to young people. They can also be made to look like everyday items such as pens and USB memory sticks. ENDS and their risks are outlined in more detail in the WMA Statement on Health Hazards of Tobacco Products and Tobacco- Derived Products.

Nicotine exposure, no matter how it is delivered, can affect brain development and lead to addiction. No standard definition of e-cigarettes exists, and manufacturers use different designs and different ingredients. Quality control processes used to manufacture e-cigarettes are substandard or non-existent, and few studies have been done to analyze the level of nicotine delivered to the user and the composition of the aerosol or vapor produced. Unknown amounts of nicotine are delivered to the user, and the level of absorption is unclear, leading to potentially toxic levels of nicotine in the system, especially in children, adolescents and young adults. E-cigarettes and ENDS may also contain other ingredients toxic or carcinogenic to humans including delivery solvents, propylene glycol, glycerin, pulegone, formaldehyde, acetaldehyde, acrolein, and heavy metals, such as chromium, copper, zinc, tin and lead.

Manufacturers and marketers of e-cigarettes and ENDS often claim that use of their products is a safe or safer alternative to smoking cigarettes, particularly since e-cigarettes and ENDS do not produce carcinogenic smoke. However, no studies have conclusively determined that the aerosol is not toxic or carcinogenic. There is some evidence of a risk of carcinogenicity of the respiratory tract due to long-term, cumulative exposure to nitrosamines and to acetaldehyde and formaldehyde. As with tobacco products, the safest option is to abstain from using e-cigarettes and ENDS.

Evidence already exists that e-cigarettes and ENDS are harmful and not safe.  Risks include:

  • appeal to children, adolescents and young adults, through packaging and marketing designed to appeal to these age groups, and especially when flavors like strawberry or chocolate are added to the cartridges. These factors can increase nicotine addiction among young people, and may be a gateway to experimenting with other tobacco products. Packaging and marketing targeted to young people has contributed to the dramatic increase in e-cigarette and ENDS use which in some regions is more popular than tobacco smoking.
  • the belief promoted by manufacturers that these devices are acceptable alternatives to scientifically proven cessation techniques, when neither their value as therapeutic aids for smoking cessation nor their safety as cigarette replacements is established. Evidence reveals that these products are harmful to health and not safe. In addition, evidence on the use of ENDS as a way to decrease tobacco use in adults is inconclusive;
  • inconsistent and unknown dosage, manufacturing processes, and ingredients, including the potential for abusing or manipulating the product, e.g., by adding cannabis, and simultaneous use with other tobacco products (dual or poly use);
  • high potential of toxic exposure to nicotine by children, either by ingestion or dermal absorption from contents of a nicotine cartridge, because the cartridges and refill liquids are readily available over the Internet and are not always sold in child resistant packaging;
  • worse clinical outcomes in patients with the SARS-COV2 virus who also use e-cigarettes.

 

RECOMMENDATIONS

  1. That e-cigarettes and ENDS be subject to the WHO Framework Convention on Tobacco Control, and to jurisdictional smoke-free laws and regulations.
  2. That the manufacture and sale of e-cigarettes and ENDS be subject to national regulatory bodies as either a new form of tobacco product or as a drug delivery device. At a minimum, regulations should address maximum strength of nicotine fluids, tank size on vaping devices, product labeling, and child-resistant packaging. This recommendation also applies to devices using synthetic nicotine.
  3. That clinical testing, large population studies and full analyses of e-cigarette ingredients and manufacturing processes be conducted to determine their level of risk, viability, and efficacy as tools for tobacco cessation.
  4. That e-cigarettes and other ENDS should never be marketed as a valid or efficacious method for smoking cessation without validated clinical research that is assessed by appropriate regulatory bodies. In all other instances, plain package marketing should be required, in accordance with the WMA Resolution on Plain Packaging of Cigarettes, e-Cigarettes and Other Smoking Product.
  5. That the sale, marketing, distribution, and accessibility of e-cigarettes and other tobacco products to children and adolescents be prohibited.
  6. That the production, distribution and sale of flavored e-cigarette cartridges and candy products that depict or resemble tobacco products be prohibited.
  7. That the sale of e-cigarettes and ENDS via the internet be prohibited in order to prevent access to these products by minors.
  8. That physicians, pediatric practitioners and dentists inform their patients of the potential risks of using e-cigarettes and ENDS, e.g., addiction, cardiovascular disease, lung disease, impact on brain development due to nicotine, physical injuries, etc., even if regulatory authorities have not taken a position on the efficacy and safety of these products.
  9. That the WMA and its members support further research on the harmful effects of e-cigarettes and ENDS, especially in children, adolescents and young adults.

Adopted by the 63rd WMA General Assembly, Bangkok, Thailand, October 2012
and revised by the 68th WMA General Assembly, Chicago, United States, October 2017

PREAMBLE

1.     Advances in medical sciences, especially surgical techniques, tissue typing and immuno-suppressive drugs, have made possible a significant increase in the rates of successful transplantation of human organs and tissue. Yet, in all countries, a shortage of organ donors results in potentially avoidable loss of life. National medical associations should support attempts to maximise the number of donor organs available in their countries and to ensure that the highest ethical standards are maintained.  The World Medical Association has developed this policy to assist medical associations, physicians, other health care providers and policy makers to achieve this.

This policy is based on a number of core ethical principles: altruism, autonomy, beneficence, equity and justice. These principles should guide those developing national policies and those operating within it, both in relation to organ procurement and to the distribution and transplantation of donor organs. All systems and processes should be transparent and open to scrutiny.

This statement applies to organ and tissue donation from both deceased and living donors. It does not apply to blood donation.

RAISING PUBLIC AWARENESS

2.     It is important that individuals are aware of the option of donation and have the opportunity to choose whether or not to donate organs and/or tissue before and after their death. Awareness and choice should be facilitated in a coordinated multi-faceted approach by a variety of stakeholders and means, including media awareness and public campaigns. In designing such campaigns account needs to be taken of any religious or cultural sensitivities of the target audience.

3. Through awareness raising campaigns, individuals should be informed of the benefits of transplantation, the impact on the lives of those who are waiting for a transplant and the shortage of donors available.  They should be encouraged to think about their own wishes about donation, to discuss their wishes with their family and friends and to use established mechanisms to formally record them by opting into, or out of, donation.

4. The WMA advocates informed donor choice. National medical associations in countries that have adopted or are considering a policy of “presumed consent” (or opt-out), in which there is an assumption that the individual wishes to donate unless there is evidence to the contrary, or “mandated choice”, in which all persons would be required to declare whether they wish to donate, should make every effort to ensure that these policies have been adequately publicised and do not diminish informed donor choice, including the patient’s right not to donate.

5. Consideration should be given to the establishment of national donor registries to collect and maintain a list of citizens who have chosen either to donate or not to donate their organs and/or tissue. Any such registry must protect individual privacy and the individual’s ability to control the collection, use, disclosure of, and access to, his or her health information for other purposes. Provisions must be in place to ensure that the decision to sign up to a register is adequately informed and that registrants can withdraw from the registry easily and quickly and without prejudice.

6. Living organ donation is becoming an increasingly important component of transplantation programmes in many countries. Most living donation is between related or emotionally close individuals and small but increasing numbers are donating to people they do not know. Given that there are health risks associated with living organ donation, proper controls and safeguards are essential. Information aimed at informing people about the possibility of donating organs as a living donor should be carefully designed so as not to put pressure on them to donate and to minimise the risk of financial or other coercion. Potential donors should know where to obtain detailed information about what is involved, should be informed of the inherent risks and should know that there are safeguards in place to protect those offering to donate.

PROTOCOLS FOR ORGAN AND TISSUE DONATION FROM DECEASED DONORS

7.     The WMA encourages its members to support the development of comprehensive, coordinated national protocols for deceased (also referred to as cadaveric) organ and tissue procurement in consultation and cooperation with all relevant stakeholders. Ethical, cultural and societal issues arising in connection with donation and transplantation should be resolved, wherever possible, in an open process involving public debate informed by sound evidence.

8.     National and local protocols should provide detailed information about the identification, referral and management of potential donors as well as communication with those close to people who have died.  They should encourage the procurement of organs and tissues consistent with this statement. Protocols should uphold the following key principles:

  • Decisions to withhold or withdraw life-prolonging treatment should be based on an assessment of whether the treatment is able to benefit the patient.  Such decisions must be, and must be seen to be, completely separate from any decisions about donation.
  • The diagnosis of death should be made according to national guidelines and as outlined in the WMA’s Declaration of Sydney on the Determination of Death and Recovery of Organs.
  • There should be a clear separation between the treating team and the transplant team. In particular, the physician who declares or certifies the death of a potential donor should not be involved in the transplantation procedure. Nor should he/she be responsible for the care of the organ recipient.
  • Countries that carry out donation following circulatory/cardiac death should have specific and detailed protocols for this practice.
  • Where an individual has expressed a clear and voluntary wish to donate organs and/or tissue after death, steps should be taken to facilitate that wish wherever possible.  This is part of the treating team’s responsibility to the dying patient.
  • The WMA considers that the potential donor’s wishes are paramount. Relatives and those close to the patient should be strongly encouraged to support a deceased person’s previously expressed wish to donate organs and/or tissues. Whenever possible, these conversations should occur prior to the death of the patient.
  • Those charged with approaching the patient, family members or other designated decision maker about organ and tissue donation should possess the appropriate combination of knowledge, skill and sensitivity for engaging in such discussions. Medical students and practising physicians should seek the necessary training for this task, and the appropriate authorities should provide the resources necessary to secure that training.
  • Donation must be unconditional. In exceptional cases, requests by potential donors, or their substitute decision makers, for the organ or tissue to be given to a particular recipient may be considered if permitted by national law.  Donors seeking to apply conditions that could be seen as discriminatory against certain groups, however, should be declined.

9.     Hospitals and other institutions where donation occurs should ensure that donation protocols are publicised amongst those likely to use them and that adequate resources are available for their implementation.  They should also foster a pro-donation culture within the institution in which consideration of donation is the norm, rather than the exception, when a patient dies.

10.  The role of transplant coordination is critical to organ donation. Those performing coordination act as the key point of contact between the bereaved family and the donation team and usually also undertake the complex logistical arrangements to make donation happen. Their role must be recognised and supported.

11.  Deceased organ donation must be based on the notion of a gift, freely and voluntarily given. It should involve the voluntary and unpressured consent of the individual provided before death (by opting in or opting out of donation depending upon the jurisdiction) or the voluntary authorisation of those close to the deceased patient if that person’s wishes are unknown. The WMA is strongly opposed to the commercialisation of donation and transplantation.

12.  Prospective donors or their substitute health care decision makers should have access to accurate and relevant information, including through their general practitioners. Normally, this will include information about:

  • The procedures and definitions involved in the determination of death,
  • The testing that is undertaken to determine the suitability of the organs and/or tissue for transplantation and that this may reveal previously unsuspected health risks in prospective donors and their families,
  • Measures that may be required to preserve organ function until death is determined and transplantation can occur,
  • What will happen to the body once death has been declared,
  • What organs and tissues can be donated,
  • The protocol that will be followed in the event that the family objects to donation, and
  • The possibility and the process of withdrawing consent.

13.  Prospective donors or their substitute health care decision makers should be given the opportunity to ask questions about donation and should have their questions answered sensitively and intelligibly.

14.  Where both organs and tissues are to be donated, information should be provided, and consent obtained, for both together in order to minimise distress and disruption to those close to the deceased.

15.  In some parts of the world a contribution towards funeral costs is given to the family of those who donate. This can be viewed either as appropriate recognition of their altruistic act or as a payment that compromises the voluntariness of the choice and the altruistic basis for donation. The interpretation may depend, in part, on the way it is set up and managed.  When considering the introduction of such a system, care needs to be taken to ensure that the core principles of altruism, autonomy, beneficence, equity and justice are met.

16.  Free and informed decision making requires not only the provision of information but also the absence of coercion. Any concerns about pressure or coercion must be resolved before the decision to donate organs or tissue is made.

17.  Prisoners and other people who are effectively detained in institutions should be eligible to donate after death where checks have been made to ensure that donation is in line with the individual’s prior, un-coerced wishes and, where the individual is incapable of giving consent, authorisation has been provided by a family member or other authorized decision-maker. Such authorisation may not override advance withholding or refusal of consent.

18.  Their death is from natural causes and this is verifiable.

19.  In jurisdictions where the death penalty is practised, executed prisoners must not be considered as organ and/or tissue donors. While there may be individual cases where prisoners are acting voluntarily and free from pressure, it is impossible to put in place adequate safeguards to protect against coercion in all cases.

ALLOCATION OF ORGANS FROM DECEASED DONORS

20.  The WMA considers there should be explicit policies, open to public scrutiny, governing all aspects of organ and tissue donation and transplantation, including the management of waiting lists for organs to ensure fair and appropriate access.

21.  Policies governing the management of waiting lists should ensure efficiency and fairness. Criteria that should be considered in allocating organs or tissue include:

  • Severity and urgency of medical need,
  • Length of time on the waiting list,
  • Medical probability of success measured by such factors as age, type of disease, likely improvements in quality of life, other complications, and histocompatibility.

22.  There must be no discrimination based on social status, lifestyle or behaviour. Non-medical criteria must not be considered.

PROTOCOLS FOR ORGAN AND TISSUE DONATION FROM LIVING DONORS

23.  Living donation is becoming increasingly common as a way to overcome the shortage of organs from deceased donors. In most cases donors provide organs to relatives or people to whom they are emotionally close. A small number of individuals choose to donate an organ altruistically to a stranger. Another scenario is where one or more donor and recipient pairs are incompatible with each other but donate in the form of a cross-over or pooled donation system (for example, donor A donates to recipient B, donor B donates to recipient C and donor C donates to recipient A).

24.  All potential donors should be given accurate and up to date information about the procedure and the risks of donation and have the opportunity to discuss the issue privately with a member of the healthcare team or a counsellor.  Normally this information will include:

  • The risks of becoming a living donor,
  • The tests that are undertaken to assess suitability for donation and that this may reveal previously unsuspected health problems,
  • What will happen before, during and after donation takes place, and
  • In the case of solid organs, the long-term implications of living without the donated organ.

25.  Prospective donors should be given the opportunity to ask questions about donation and should have their questions answered sensitively and intelligibly.

26.  Procedures should be in place to ensure that living donors are acting voluntarily and free from pressure or coercion. In order to avoid donors being paid and then posing as a known donor, independent checks should also be undertaken to verify the claimed relationship and, where this cannot be proven, the donation should not proceed. Such checks should be independent of the transplant team and those who are caring for the potential recipient.

27.  Additional safeguards should be in place for vulnerable donors, including but not limited to, people who are dependent in some way (such as competent minors donating to a parent or sibling).

28.  Prisoners should be eligible to be living donors only in exceptional circumstances, to first or second degree family members; evidence should be provided of any claimed relationship before the donation may proceed. Where prisoners are to be considered as living donors, extra safeguards are required to ensure they are acting voluntarily and are not subject to coercion.

29.  Those who lack the capacity to consent should not be considered as living organ donors because of their inability to understand and decide voluntarily. Exceptions may be made in very limited circumstances, following legal and ethical review.

30.  Donors should not lose out financially as a result of their donation and so should be reimbursed for general and medical expenses and any loss of earnings incurred.

31.  In some parts of the world individuals are paid for donating a kidney, although in virtually all countries the sale of organs is unlawful. The WMA is strongly opposed to a market in organs.

PROTOCOLS FOR RECIPIENTS

32.  Protocols for free and informed decision making should be followed in the case of recipients of organs or tissue. Normally, this will include providing information about:

  • The risks of the procedure,
  • The likely short, medium and long-term survival, morbidity, and quality-of-life prospects,
  • Alternatives to transplantation, and
  • How organs and tissues are obtained.

33.  In the case of a delayed diagnosis for infection, disease or malignancy in the donor, there should be a strong presumption that the recipient will be informed of any risk to which they may have been exposed. Individual decisions about disclosure need to take account of the particular circumstances, including the level and severity of risk. In most cases disclosure will be appropriate and should be managed carefully and sensitively.

COSTS AND ORIGIN OF ORGANS AND TISSUES

34.  Organs or tissue suspected to have been obtained through unlawful means must not be accepted for transplantation.

35.  Organs and tissues must not be sold for profit.  In calculating the cost of transplantation, charges related to the organ or tissue itself should be restricted to those costs directly associated with its retrieval, storage, allocation and transplantation.

36.  Transplant surgeons should seek to ensure that the organs and tissues they transplant have been obtained in accordance with the provisions of this policy and should refrain from transplanting organs and tissues that they know, or suspect, have not been procured in a legal and ethical manner.

TRANSPARENCY AND ACCOUNTABILITY

37.  National Medical Associations should work with governments and relevant institutions to ensure that appropriate, effective structures and processes are in place to:

  • support relevant traceability and follow-up of all transplant recipients and living donors including those who require ongoing medical management receive care and support;
  • record information on donation and transplantation rates and outcomes;
  • assess the short and long-term outcomes, quality, safety and efficacy of organ donation and transplantation activities;
  • assess the adherence to ethical and clinical protocols of organ donation and transplantation activities;

38.  The data arising from these activities should be publicly accessible and open to scrutiny (notwithstanding appropriate protection of donor and recipient confidentiality).

FUTURE OPTIONS

39.  Public health measures to reduce the demand for donated organs should be seen as a priority, alongside initiatives to increase the effectiveness and success of organ donation systems.

40.  New developments and possibilities, such as xenotransplantation and the use of stem cell technology to repair damaged organs, should be monitored. Before their introduction into clinical practice such technologies should be subject to scientific review and robust safety checks as well as ethical review. Where, as with xenotransplantation, there are potential risks that go beyond individual recipients, this process must also involve public debate.

Adopted by the 63rd WMA General Assembly, Bangkok, Thailand, October 2012
and revised by the 73rd WMA General Assembly, Berlin, Germany, October 2022

 

PREAMBLE

Violence in the health sector has increased substantially in the new millennium, especially in time of COVID-19 pandemic. All persons have the right to work in a safe environment without the threat of violence. Workplace violence includes both physical and non-physical, such as (psychological) violence, intimidation and cyber harassment, among others.

Cyber and social media harassment particularly includes online threats and intimidation towards physicians who take part in a public debate in order to give adequate information and fight disinformation. These physicians are increasingly confronted with, amongst others, malicious messages on social media, death threats and intimidating home visits.

For the purposes of this document, the broad WHO definition of workplace violence will be used: “The intentional use of power, threatened or actual, against another person or against a group, in work-related circumstances, that either results in or has a high degree of likelihood of resulting in injury, death, psychological harm, mal-development, or deprivation”.

In addition to the numerous consequences on victims’ health, violence against health personnel has potentially destructive social effects. It affects the entire healthcare system and undermines the quality of the working environment, ultimately impacting the quality of patient care. Furthermore, violence can affect the availability of health care, particularly in impoverished areas.

While workplace violence is indisputably a global issue, various cultural differences among countries must be taken into consideration in order to accurately understand the concept of violence on a universal level.  Significant differences exist in terms of what defines various levels of violence and what specific forms of workplace violence are most likely to occur. This may create tolerance for some levels of violence in those places. However, threats and other forms of psychological violence are widely recognized to be more prevalent than physical violence.

Causes of violence in the healthcare setting are extremely complex. Several studies have identified common triggers for acts of violence by patients and relatives to be delays in receiving treatment, dissatisfaction with the treatment provided, aggressive patient behavior caused by the patient’s medical condition, the medication they take or the use of alcohol and other drugs. Additionally, individuals may threaten or perpetrate violence against health personnel because they oppose a specific area of medical practice, based on their social, political or religious beliefs. Cases of violence from the bystanders are reported as well. Co-worker violence, such as bullying, including initiation ceremonies and practical jokes, or harassment, constitutes another important pattern of workplace violence in the health sector.

Collaboration among various stakeholders (including governments, medical associations, hospitals, general health services, management, insurance companies, trainers, preceptors, researchers, media, police and legal authorities) together with a multi-faceted approach encompassing the areas of legislation, security, data collection, training/education, environmental factors, public awareness and financial incentives is required in order to successfully address this issue. As the representatives of physicians, medical associations should take a proactive role in combating violence in the health sector and also encourage other key stakeholders to act, thus further protecting the quality of the working environment for health personnel and the quality of patient care.

 

RECOMMENDATIONS

The WMA condemns in the strongest terms any forms of violence against healthcare personnel and facilities, which may include coworker violence, aggressive behavior exhibited by patients or family members, as well as acts of malicious intent from individuals in the general public, and calls on its constituent members, the health authorities and other relevant stakeholders to act through a collaborative, coordinated and effective strategy approach:

Policy-making

  1. The state has obligations to ensure the safety and security of patients, physicians, and other health personnel. This includes providing an appropriate physical environment.
  2. Governments should provide the necessary framework so that the prevention and elimination of workplace violence in the health sector be an essential part of national/regional/local policies on occupational health and safety, human rights protection, healthcare-facility management standards and gender equality.

Financial

  1. Governments should allocate appropriate and sustainable funds in order to effectively tackle violence in the health sector.

Protocols for situation of violence in healthcare facilities

  1. Healthcare facilities should adopt a zero-tolerance policy towards workplace violence eliminating its “normalization” through the development and implementation of adequate protocols including the following:
  • A predetermined plan for maintaining security in the workplace; including recognition of non-physical abuse as a risk factor for physical abuse.
  • A designated plan of action for health personnel when violence takes place.
  • A strengthened internal communication strategy, involving the staff in decisions concerning their security.
  • A system for reporting and recording acts of violence, which may include reporting to legal and/or police authorities.
  • A means to ensure that employees who report violence do not face reprisals.
  1. In order for these protocols to be effective, the management and administration of healthcare facilities should communicate and take the necessary steps to ensure that all staff are aware of the protocols. Managers should be urged to verbalize a no-tolerance policy towards violence in healthcare settings.
  2. Patients with acute, chronic or illness-induced mental health disturbances or other underlying medical conditions may act violently toward health personnel; those taking care of these patients must be adequately protected. Except in emergency cases, physicians might have the right to refuse to treat and, in such situations, they must ensure that adequate alternative arrangements are made by the relevant authorities in order to safeguard the patient’s health and treatment.

Training/Education

  1. A well-trained and vigilant staff supported by management can be a key deterrent of violent acts. Constituent members should work with undergraduate and postgraduate education providers to ensure that health personnel are trained in the following areas: communication skills, empathy as well as recognising and handling potentially violent persons and high-risk situations in order to prevent incidents of violence.
  2. Continuous education should include ethical principles of healthcare and the cultivation of the patient-physician relationships based on respect and mutual trust. This not only improves the quality of patient care but also fosters feelings of security resulting in a reduced risk of violence.

Communication and Social Awareness

  1. Medical associations, health authorities and other stakeholders should work together to increase awareness of violence in the health sector, creating networks of information and expertise in this area. When appropriate, health personnel and the public should be informed of acts of violence.
  2. Broadcasting agencies, newspapers, and other news outlets are encouraged to thoroughly verify their sources in order to keep the information shared to the highest standard of professional reporting. Social media companies and associated stakeholders should also take active steps to create a cyber-violence-free environment for its users. This includes strengthening policies to protect user data, making reporting and flagging such violence easy and accessible, and engaging law enforcement for proper legal action when warranted.

Security

  1. Appropriate security measures should be in place in all healthcare facilities and acts of violence should be given a high priority by law-enforcement authorities. A routine violence risk audit, including a risk assessment, should be implemented in order to identify which jobs and locations are at highest risk for violence, especially in places where violence has already occurred, and to determine weaknesses in facilities’ security. Examples of high-risk areas include general practice premises, mental health treatment facilities and high traffic areas of hospitals including the emergency department.
  2. The risk of violence may be ameliorated by a variety of means which include placing security personnel in high-risk areas and at the entrance of buildings, the installation of security cameras and alarm devices for use by health personnel, the use distinguishable items to identify the staff and by maintaining sufficient lighting in work areas, contributing to an environment conducive to vigilance and safety. The implementation of a system to screen patients and visitors for weapons upon entering certain areas, especially the high-risk ones, should be considered.

Support to victims

  1. Adequate medical, psychological and legal support should be provided to victims of violence. Such support should be free of access for all the health personnel.

Investigation

  1. In all cases of violence there should be investigation to better understand the causes and to aid in prevention of future violence. The investigation may lead to prosecution of perpetrators under civil or criminal codes. The procedure should be led by relevant officials in law enforcement and should not expose the victim to further physical or psychological harm.

Data Collection

  1. Appropriate reporting systems should be established to enable health personnel to report anonymously and without reprisal, any threats or incidents of violence. Such a system should assess in terms of number, type and severity, incidents of violence within an institution and resulting injuries. The system should be used to analyse the effectiveness of preventative strategies. Aggregated data and analyses should be made available to health professional organizations and other relevant stakeholders.

Adopted by the 10th World Medical Assembly, Havana, Cuba, October 1956,
edited by the 11th World Medical Assembly, Istanbul, Turkey, October 1957,
revised by the 35th World Medical Assembly, Venice, Italy, October 1983 and the 55th WMA General Assembly, Tokyo, Japan, October 2004,
editorially revised by the 173rd WMA Council Session, Divonne-les-Bains, France, May 2006, and
revised by the 63rd WMA General Assembly, Bangkok, Thailand, October 2012 and the 74th WMA General Assembly, Kigali, Rwanda, October 2023*

*The WMA Regulations of the WMA in times of armed conflict and other situations of violence adopted in 1956 were reclassified as a ‘Statement’ by the 63rd General Assembly, Kigali, Rwanda, October 2023.

 

 

PREAMBLE

The primary task of the medical profession is to promote health and save life; the primary obligation of the physicians is to their patients; in all their professional activities, physicians should adhere to international conventions on human rights, to international humanitarian law and to the WMA’s Declaration of Geneva, International Code of Medical Ethics and other relevant WMA declarations on medical ethics[1], as well as to the Ethical Principles of Health Care in Times of Conflict and Other Emergencies, elaborated by civilian and military healthcare organisations, including the WMA, under the initiative of the International Committee of the Red Cross.

In situations of armed conflict and other situations of violence, governments, belligerent armed forces and others in positions of power must comply with their obligations in accordance with international law, including, as applicable, Geneva Conventions (1949) and the Additional Protocols to the Geneva Conventions (1977, 2005).

This obligation includes a requirement to protect healthcare personnel and facilities (see e.g. the WMA Declaration on the protection and integrity of healthcare personnel in armed conflicts and other situations of violence, 2022), including any means of transportation devoted to the wounded and sick, to health personnel or medical equipment.

This obligation also includes condemning the targeting of health care facilities and personnel and using denial of medical services, including as a tactic or strategy in war, by any party, wherever and whenever it occurs.

The WMA supports efficient, secure and unbiased reporting mechanisms with sufficient resources to collect and disseminate data regarding assaults on physicians, other healthcare personnel and healthcare facilities, and to provide to the WHO and other relevant agencies the necessary support to fulfill their role in documenting attacks on healthcare personnel and facilities.

Assaults against healthcare personnel must be investigated and those responsible must be brought to justice; to this end, adequate enforcement mechanisms must be used, or where relevant, developed, and necessary resources must be guaranteed.

Physicians must be granted access to all persons in need of care, including those deprived of liberty.

Physicians have a responsibility to press governments and other authorities for the provision of the infrastructure and equipment that is a prerequisite to health and healthcare, including potable water, adequate food and shelter, proper infrastructure, clinical equipment and available healthcare personnel, and the necessary personal protection equipment (PPE).

Where conflict appears to be imminent and inevitable, relevant authorities are responsible for guaranteeing the protection of the health infrastructure and for planning any necessary repair in the immediate post-conflict period.

Respect of professional ethical rules

During times of armed conflict and other situations of violence, the ethical standards of the medical profession apply as in times of peace. The professional duty to treat people with humanity and respect applies to all patients. The physician must always act in accordance with medical neutrality and give the necessary care impartially and without discrimination.

Physicians must never be persecuted for complying with any of their ethical obligations, and may not be compelled by governments, armed forces or others in positions of power, to undertake any action that contravenes the medical profession’s ethical rules.

The privacy of the sick, wounded and dead must always be respected and confidentiality duly respected.

Health care given to the sick and wounded, civilians or combatants, cannot be used for publicity or propaganda.

Physicians must not spread disinformation, or manipulate facts for the public, for the media, or for the social media outlets.

Ethics training on the issue of medical treatment of prisoners of war and detainees should be provided in medical schools and during postgraduate training.

 

RECOMMENDATIONS

In situations of armed conflict and other situations of violence, the physician must:

General principles

  1. Not take part in any act of hostility and refuse any illegal or unethical order;
  2. Neither commit nor assist in violations of international law;
  3. Not abandon the wounded and sick, while considering the physician’s own safety and competence and the availability of other viable options for care;
  4. Promote medical neutrality by advocating for and providing effective and impartial patient care without discrimination; no distinction must be made between patients except based upon clinical facts;
  5. Give special consideration to the most vulnerable or marginalized parts of the population in need of care (e.g. women, children, older persons, people with specific healthcare needs, and displaced persons) and to their specific healthcare needs while adhering to triage principles;
  6. Respect the individual wounded or sick person´s autonomy, trust and dignity;
  7. Respect confidentiality, in line with the Declaration of Geneva and the International Code of Medical Ethics;
  8. Give careful consideration to any dual loyalties that the physician may be bound by or conflicts of interest that may be present.

Detention

  1. Provide healthcare to anyone taken as a prisoner;
  2. Advocate for regular visits to prisons and prisoners by physicians;
  3. Never condone, facilitate or participate in the practice of torture or any form of cruel, inhuman or degrading treatment, nor in any form of abuse, including forced feeding, human trafficking or human organ trafficking;
  4. In line with the WMA International Code of Medical Ethics, the WMA Declaration of Tokyo, the WMA Statement on the Responsibility of Physicians in the Documentation and Denunciation of Acts of Torture or Cruel or Inhuman or Degrading Treatment, the Istanbul Protocol and the United Nations Standard Minimum Rules for the Treatment of Prisoners (the Nelson Mandela Rules), denounce acts of torture or cruel, inhuman or degrading treatment and punishments.

Forbidden activities

  1. Never use the situation and the vulnerability of the wounded and sick for personal advantage;
  2. Never make use of healthcare privileges and facilities contrary to their intended purposes;

Public Health

  1. Report to the appropriate authorities if healthcare needs are not met;
  2. Respect the legal obligations to report to the appropriate authorities in matters of epidemiology;
  3. Respect the WMA Declarations of Helsinki and the WMA Declaration of Taipei on research and data management;
  4. Denounce and intervene against any unscrupulous practices, including distribution of poor quality or counterfeit medicines and materials;
  5. Be aware of war-related mental health trauma when caring for patients, internally displaced persons and refugees.

 

 

[1] WMA Declaration on the Protection and Integrity of Medical Personnel in Armed Conflicts and Other Situations of Violence / WMA Statement on Armed Conflicts

 

Adopted by the 63rd WMA General Assembly, Bangkok, Thailand, October 2012
and reaffirmed with minor revisions by the 221st WMA Council Session, Berlin, Germany, October 2022

Preamble

In recent years, in countries where physicians’ satisfaction with their working conditions has decreased, collective action by physicians to advocate for better conditions has become increasingly common.

Physicians may carry out protests and sanctions, including collective resignations, in order to improve direct and indirect working conditions and to ensure safe and resilient health care systems. Physicians must consider not only their duty to individual patients, but also their responsibility to improve the system, such that it meets the requirements of accessibility and quality.

In addition to their professional obligations, physicians are often also employees. There may be tension between physicians’ duty not to cause harm, and their rights as employees. Therefore, physicians’ strikes or other forms of collective action often give rise to public debate on ethical and moral issues. This statement attempts to address these issues.

 

RECOMMENDATIONS

The World Medical Association recommends that Constituent Members adopt the following guidelines for physicians with regard to collective action:

  1. Physicians who take part in collective action are not exempt from their ethical or professional obligations to patients.
  2. Even when the action taken is not organized by or associated with the Constituent Member, the Constituent Member should ensure that the individual physician is aware of and abides by their ethical obligations.
  3. Whenever possible, physicians should press for reforms through non-violent public demonstrations, lobbying and publicity or informational campaigns, and/or through negotiation or mediation.
  4. If involved in collective action, Constituent Members should act to minimize the harm to the public and ensure that essential and emergency health services, and the continuity of care, are provided throughout a strike. Further, Constituents Members should advocate for measures to review exceptional cases. If involved in collective action, Constituent Members should provide continuous and up-to-date information to their patients and the general public with regard to the demands of the conflict and the actions being undertaken. The general public must be kept informed in a timely manner about any strike actions and the restrictions they may have on health care.

 

Adopted by the 63rd WMA General Assembly, Bangkok, Thailand, October 2012, and
revised by the 74th WMA General Assembly, Kigali, Rwanda, October 2023

 

PREAMBLE

The United Nations states forced or coerced sterilisation is a violation of fundamental human rights, including the right to health, to information and privacy, and to be free from torture and other cruel, inhuman or degrading treatment or punishment. The United Nations also states specific populations are disproportionately affected by forced or coerced sterilisation, including women, women living with HIV, indigenous and ethnic minority girls and women, persons with disabilities, and transgender persons and intersex persons.

The WMA recognises that no person, regardless of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, culture, sexual orientation, social standing, or any other factor, should be subjected to forced or coerced sterilisation.

A full range of contraceptive services, including sterilisation, should be accessible and affordable to every individual. The state has a role to play in ensuring that such services are available, along with private, charitable and third sector organisations.

As with all other medical treatments, sterilisation should only be performed on a competent patient after an informed choice has been made and the free and valid consent of the individual has been obtained. Where a patient is incompetent, a valid decision about treatment must be made in accordance with the patient’s best interest as well as with relevant legal requirements and the ethical standards of the medical profession before the procedure is carried out.

The WMA condemns practices where a state or any other actor attempts to bypass ethical requirements necessary for obtaining free and valid consent for sterilization, which must be:

  • Free from material or social coercion;
  • Not a condition of other medical care (including safe abortion), social, insurance, institutional or other benefits and
  • Obtained when the person is not facing any stressor limiting their capacity of discernment, such as detention or a medical emergency (unless sterilization is the subject of the emergency).

 

RECOMMENDATIONS

Recalling the core ethical values of the medical profession enshrined in its International Code of Medical Ethics and the Declaration of Geneva: The Physician’s Pledge, and its long-standing commitment against torture and other cruel, inhuman or degrading treatment, the WMA condemns forced or coerced sterilisation and calls on:

Its Constituent Members

1. To advocate against such practices contrary to human dignity;

2. To support the provision of safe and ethical sterilization services or interventions, with due respect for the physical and mental integrity of the persons, including by guaranteeing their autonomous reproductive choices;

Physicians

3. To be alert to situations and settings where there is a risk of forced or coerced sterilisation, particularly for vulnerable and disproportionately affected persons, to ensure consent is valid and freely given and to oppose any form of involvement in forced or coerced sterilisation.

Adopted by the 62nd WMA General Assembly, Montevideo, Uruguay, October 2011
and revised by the 73rd WMA General Assembly, Berlin, Germany, October 2022

 

DEFINITION

 Social media is a collective term for the different interactive platforms, websites and applications intended for digital networking, that allow individuals and organizations to create and share user-generated content digitally.

The objectives of this policy are to:

  • Examine the professional and ethical challenges related to the increasing usage of social media by physicians, medical students, and patients.
  • Establish a framework that protects their respective interests.
  • Ensure trust and reputation by maintaining high professional and ethical standards.
  • Promote the availability of quality information across social media.
  • Stand against misinformation and disinformation on social media.

The use of social media has become a fact of life for billions of people worldwide including physicians, medical students, and patients.

Interactive, collaborative tools such as wikis, social networking platforms, chat applications and blogs have transformed passive Internet users into active participants. These tools are means for gathering, sharing and disseminating information, including healthcare and science information, socializing and connecting with friends, relatives, professionals etc. They can be used to seek medical advice, and patients share their health and healthcare experiences. They can also be used in research, public health, and education.

The positive aspects of social media should be recognized such as in promoting a healthy lifestyle, the dissemination of medical knowledge to society and in reducing patients’ isolation.

Areas, which may require special attention include:

  • Sensitive content, photographs, videos, other personal materials posted on online social forums often exist in the public domain and have the capacity to remain on the internet permanently. Individuals may not have control over the ultimate distribution of material they post on-line.
  • Patient portal, blogs and tweets are not a substitute for one on one consultation with physicians but may widen engagement with health services amongst certain groups. Online “friendships” with patients may also alter the patient-physician relationship, and may result in unnecessary, possibly problematic physician and patient self-disclosure.
  • Each party’s privacy may be compromised in the absence of adequate and conservative privacy settings or by their inappropriate use. Privacy settings are not absolute; social media sites may change default privacy settings unilaterally, without the user’s knowledge. Social media sites may also make communications available to third parties.
  • Misinformation and disinformation often spread more rapidly through social media than fact-based accurate information. It may cause harm to the health of individuals as well as to public health and foster doubt and distrust towards professionals seeking to promote truth and science-based evidence.
  • Appropriate disclaimers to include in biographical information (e.g., “my opinions are my own”, “posts are not personalized medical advice”, etc).

The dissemination of medical knowledge, best practices and treatment options on social media can increase and expedite access to new and valid information among medical professionals. However, individuals or companies can take advantage of these channels in misleading ways, including to market or promote their medical products or treatments.

 

RECOMMENDATIONS

The WMA urges National Medical Associations (NMA) to establish social media guidelines for their members addressing the following objectives:

  1. To maintain appropriate boundaries of the patient-physician relationship in accordance with professional ethical guidelines just as they would in any other context.
  2. To ensure that no identifiable patient information is posted in any social media by their physician, by increasing the understanding of privacy provisions of social networking sites and their limitations while considering intended audience and the technical feasibility to restrict access to the content to predefined individuals or groups.
  3. To exercise care when using applications that might compromise the security of the data, including when consulting with colleagues.
  4. To promote and apply the principles in the WMA Guidelines on Promotional Mass Media Appearances by Physicians to all social media activities by physicians.
  5. To encourage physicians to routinely monitor their own Internet presence to ensure that the personal and professional information on their own sites and, to the extent possible, content posted about them by others is accurate and appropriate.
  6. To prevent the use of technological devices from diverting our attention during direct consultation with the patient.
  7. To provide factual, concise, understandable information, declare any conflicts of interest and adopt a sober tone when discussing professional matters.
  8. To avoid inappropriate use of the networks, frivolous, insensitive attitudes or light-hearted opinions on medical matters.
  9. To draw the attention of physicians to the fact that social media content posted by health professionals may contribute to the public perception of the profession and should be done in accordance with the principles in the WMA Declaration of Geneva and the International Code of Medical Ethics.
  10. To include education on the use of social media in medical curricula and continuing medical education.
  11. To behave in the media and on social networks with the same scientific rigor and the same approach as in a consultation and show the same respect to patients and colleagues.
  12. To create mechanisms for accountability in professional settings when inappropriate behavior on social media is observed and reported.
  13. To promote health literacy and knowledge among populations and with individual patients by using objective and evidence based messages in accordance with the principles in the WMA Declaration of Geneva, the WMA International Code of Medical Ethics, and the WMA Statement on Healthcare Information for All.
  14. To combat misinformation, disinformation, and the promotion of pseudoscience and pseudotherapy on social media, all of which can result in negative health outcomes for patients and communities.
  15. To counsel fellow physicians who engage in misinformation, disinformation, or violation of patient trust on social media and/or report to relevant authorities for ongoing deliberate acts of the same.
  16. To raise awareness among physicians and medical students about the possibility that information shared on social media could be used in misleading ways by individuals or companies.

 

 

Adopted by the 62nd WMA General Assembly, Montevideo, Uruguay, October 2011,
and reaffirmed with minor revisions by the 218th Council session (online), London, United Kingdom, October 2021 

 

The WMA reaffirms its Declaration of Tokyo establishing guidelines for physicians concerning torture and other cruel, inhuman or degrading treatment or punishment in relation to detention and imprisonment, and recommends that a monitoring and reporting mechanism be established to permit audit of adherence of States to the terms of the said declaration, in particular: 

  1. Where physicians are working in situations of dual loyalties, support must be offered to ensure they are not put in positions that might lead to violations of fundamental professional ethics, whether by active breaches of medical ethics or omission of ethical conduct, and/or of human rights, as laid out in the Declaration of Tokyo. 
  2. Its constituent members should offer support for physicians in difficult situations, including, as feasible and without endangering either patients or doctors, helping individuals to report violations of patients’ health rights and physicians’ professional ethics in custodial settings. The support given must adhere to the principles put forward in the WMA Resolution on the Responsibility of Physicians in the Documentation and Denunciation of Acts of Torture or Cruel or Inhuman or Degrading Treatment. 
  3. The WMA should review the evidence available of the violation of human rights codes by states and/or the forcing of physicians to violate the Declaration of Tokyo and refer as appropriate such cases to the relevant national and international authorities. 
  4. The WMA should encourage its member associations to investigate accusations of physician involvement in torture and similar abuses of human rights reported to it from reputable sources, and to report back in particular on whether physicians are at risk and in need of support.  
  5. The WMA should provide support to its constituent members and their individual physicians members to resist such violations, and as far as realistically possible, stand firm in their ethical convictions. The medical profession and governments should also protect physicians endangered because they adhere to their professional and ethical obligations. 
  6. The WMA shall encourage and support its member associations in their calls for investigations by the relevant United Nations special rapporteur or any other standard and reliable accountability mechanism in place when valid concerns are raised. 

Adopted by the 62nd WMA General Assembly, Montevideo, Uruguay, October 2011
and revised by the 73rd WMA General Assembly, Berlin, Germany, October 2022

 

PREAMBLE

Chronic non-communicable diseases (NCDs), are the leading cause of mortality and disability in both the developed and developing world. The four main NCDs are cancers, cardiovascular diseases, chronic respiratory diseases, and diabetes (referred to as NCD4 hereafter) and they account for seven of every ten deaths worldwide. Eighty per cent of deaths due to NCDs occur in low- and middle-income countries (WHO).

NCD4 are not replacing existing causes of disease and disability, such as infectious disease and trauma, but are adding to the disease burden. While all countries face the triple burden of infectious diseases, traumas and chronic diseases, it is a much more difficult challenge for developing countries. This increased burden is straining the capacity of many countries to provide adequate healthcare services as well as increase life expectancy.

Chronic diseases are not equally distributed, which has a significant effect on health inequalities. For example, NCDs occur more frequently among socioeconomically underprivileged individuals with inferior chronic disease outcomes. Conversely, life expectancy and other health outcomes are markedly higher in more developed countries than in less developed countries, and in the higher socio-economic segments of society.

In addition, this burden is also undermining nations’ efforts to spur economic growth. NCDs are a barrier to development. In low- and middle-income countries (LMICs), poverty exposes people to lifestyle-mediated risk factors for NCDs and in turn, resulting NCDs become an important driver for poverty. Chronic diseases and poverty are linked in a vicious circle, hindering economic development and worsening poverty.

Ongoing and anticipated global trends that will lead to more chronic disease problems in the future include an aging population, urbanization and inadequate community planning, increasingly sedentary lifestyles, increasing psychosocial stress, climate change and the rapidly increasing cost of medical technology to treat NCDs. Chronic disease prevalence is closely linked to global social and economic development, globalization and mass marketing of unhealthy foods and other products.

The prevalence and cost of addressing the chronic disease burden is expected to rise in coming years. In addition to the individual and public expenses, chronic diseases lead to a marked economic burden because of the mutual effects of healthcare costs and lost productivity from disability and death. The WHO considers the global burden of chronic diseases as one of the most important challenges facing the field of health for this century.

 The rapid increase in chronic diseases represents a major health challenge for global development, for which immediate global action is needed.

Eighty percent of the global burden of chronic diseases affects LMICs, where most of the world’s population lives. The impact of this devastating burden is constantly growing. Chronic diseases and poverty are linked in a vicious circle, hindering economic development and worsening poverty.

Solutions

The NCD4 merit global attention. The primary solution for these diseases is prevention. Tobacco use, poor diet, physical inactivity and alcohol abuse are the four most common modifiable risk factors for NCDs. Poor mental health has recently been included as an additional risk factor for NCD. National policies that help people achieve healthy lifestyles and behaviours are the foundation for all possible solutions.

Increased access to primary care combined with well-designed and affordable disease-control, disease prevention and health promotion programs can greatly improve healthcare. Partnerships of national ministries of health with institutions in developed countries may overcome many barriers in the poorest settings. In addition, having health insurance improves health outcomes. Conversely, in some countries the lack of health insurance hinders the practice of preventive and primary care and is linked with adverse health outcomes. Uninsured individuals may postpone pursuing assistance when ill or injured, and they are more likely to be hospitalized for chronic illnesses such as diabetes or hypertension. Furthermore, children without health insurance are less likely to receive immunizations, and regular primary care.

Medical education systems should become more socially accountable. The World Health Organization (WHO) defines social accountability of medical schools as the obligation to direct their education, research and service activities towards addressing the priority health concerns of the community, region, or nation they have a mandate to serve. The priority health concerns are to be identified jointly by governments, health care organizations, health professionals and the public. There is an urgent need to adopt accreditation standards and norms that support social accountability and community engagement. Educating physicians and other health care professionals to deliver health care that is concordant with the needs of the population and the resources of the country must be a primary consideration. Led by primary care physicians, teams of physicians, nurses and community health workers will provide care that is driven by the principles of quality, equity, relevance and effectiveness.

Distributions of funds for health should be based on all individual nation needs. No nation can accomplish positive NCD4 outcomes by tackling a single cause of death.

Strengthening the healthcare infrastructure, including training the primary healthcare team, chronic disease surveillance, public health promotion campaigns, quality assurance and establishment of national and local standards of care, is important in caring for the increasing numbers of patients with NCD4. Most premature deaths due to NCDs are preventable; however, in most developing countries health systems are inadequate, or unprepared to appropriately act on NCDs.

One of the most important components of healthcare infrastructure is human resources; well-trained and motivated health care professionals led by primary care physicians are crucial to success. International aid and development programs need to move from “vertical focus” on single diseases or objectives to a more sustainable and effective primary care health infrastructure development.

 

RECOMMENDATIONS

Recalling its Statement on Hypertension and Cardiovascular Disease and its Declaration of Oslo on Social Determinants of Health, the WMA calls on:

National Governments to:

  1. Recognize the importance of socio-economic development for health and reduce socioeconomic status disparities in income, education, and occupation;
  2. Support global immunization strategies;
  3. Support global tobacco and alcohol control strategies, as well as control strategies addressing other forms of addiction, particularly drug use;
  4. Promote healthy living and implement comprehensive, collaborative policies and strategies at all relevant levels and divisions of government that support prevention and healthy lifestyle behaviours;
  5. Set aside a fixed percentage of the national budget for healthcare infrastructure development and promotion of healthy lifestyles and invest in better management of NCDs4 including detection, care and treatment;
  6. Advocate for trade / commercial agreements that protect rather than undermine public health;
  7. Develop and execute global and national action strategies for mitigating the health effects of climate change;
  8. Promote research for prevention and treatment of NCDs, including research on occupational health hazards leading to chronic diseases;
  9. Promote access to good quality effective medicines to treat NCDs;
  10. Develop monitoring and surveillance systems for NCDs and,
  11. Reinforce primary health care, human resources and infrastructure.

Its Constituent Members to:

  1. Increase physician, public and NGO awareness of optimal disease prevention behaviours;
  2. Enhance skills and capacity to promote a team-based multidisciplinary approach to chronic disease management;
  3. Advocate for integration of NCD prevention and control strategies in government-wide policies;
  4. Promote high quality training and professional associations for more primary care physicians and advocate for their equitable distribution;
  5. Advocate for high quality readily accessible resources for continuing medical education that is responsive to societal needs;
  6. Support establishing evidence-based standards of care for NCDs;
  7. Promote an environment of support for continuity of care for NCDs, including collaborative efforts to encourage patient education and self-management;
  8. Support strong public health infrastructure and,
  9. Recognize and support the concept that addressing and acting on social determinants are part of prevention and health care.

Medical Schools to:

  1. Develop curriculum objectives that meet current societal needs;
  2. Create primary care departments;
  3. Provide community-oriented and community-based primary care training opportunities in primary care specialties that allow students to become acquainted with the basic elements of chronic care infrastructure and continuity of care;
  4. Promote the use of interdisciplinary, interprofessional, intersectoral and other collaborative training methodologies within primary and continuing education programs and,
  5. Include instruction in chronic disease prevention, including nutrition and lifestyle promotion counselling, in the general curriculum.

Individual Physicians to:

  1. Work to create communities that promote healthy lifestyles and prevention behaviours;
  2. Offer patients smoking cessation, weight control strategies, substance abuse counselling, early screening, self-management education and support, nutritional counselling, and ongoing coaching;
  3. Inform patients about the dangers of illusory or insufficiently proven remedies or procedures, and charlatanism practices;
  4. Promote a team-based multidisciplinary and value-based approach to chronic disease management;
  5. Ensure continuity of care for patients with chronic disease;
  6. Model healthy lifestyles by maintaining personal health;
  7. Become community advocates for improved social determinants of health, equity in health care and for best prevention methods and,
  8. Work with parents and the community at large to ensure that parents have the best advice on maintaining the health of their children.

Adopted by the 61st WMA General Assembly, Vancouver, Canada, October 2010
and amended by the 69th WMA General Assembly, Reykjavik, Iceland, October 2018

Preamble

  1. This Statement focuses on one important aspect of environmental degradation, which is environmental contamination by domestic and industrial substances. It emphasizes the harmful chemical contribution to environmental degradation and physicians’ role in promoting sound management of chemicals as part of sustainable development, especially in the healthcare environment.
  2. Unsafe management of chemicals has potential adverse impacts on human health and human rights, with vulnerable populations being most at risk.
  3. Most chemicals to which humans are exposed come from industrial sources and include, toxic gases, food additives, household consumer and cosmetic products, agrochemicals, and substances used for therapeutic purposes, such as drugs and dietary supplements. Recently, attention has been concentrated on the effects of human engineered (or synthetic) chemicals on the environment, including specific industrial or agrochemicals and on new patterns of distribution of natural substances due to human activity. As the number of such compounds has multiplied, governments and international organizations have begun to develop a more comprehensive approach to their safe regulation. The increasing amount of plastic waste in our environment is another serious concern, that needs to be addressed.
  4. While governments have the primary responsibility for establishing a framework to protect the public’s health from chemical hazards, the World Medical Association, on behalf of its members, emphasizes the need to highlight the human health risks and make recommendations for further action.

BACKGROUND

Chemicals of Concern

  1. During the last half-century, the use of chemical pesticides and fertilizers dominated agricultural practice and manufacturing industries rapidly expanded their use of synthetic chemicals in the production of consumer and industrial goods.
  2. The greatest concern relates to chemicals, which persist in the environment, have low rates of degradation, bio-accumulate in human and animal tissue (concentrating as they move up the food chain), and which have significant harmful impacts on human health and the environment (particularly at low concentrations). Some naturally occurring metals including lead, mercury, and cadmium have industrial sources and are also of concern. Advances in environmental health research including environmental and human sampling and measuring techniques, and better information about the potential of low dose human health effects have helped to underscore emerging concerns.
  3. Health effects from chemical emissions can be direct (occurring as an immediate effect of the emission) or indirect. Indirect health effects are caused by the emissions’ effects on water, air and food quality as well as the alterations in regional and global systems, such as red tide in many oceans, and the ozone layer and the climate, to which the emissions may contribute.

National and International Actions

  1. The model of regulation of chemicals varies widely both within and between countries, from voluntary controls to statutory legislation. It is important that all countries move to a coherent, standardized national legislated approach to regulatory control.  Furthermore, international regulations must be coherent such that developing countries will not be forced by economic circumstances to accept elevated toxic exposure levels.
  2. Synthetic chemicals include all substances that are produced by, or result from, human activities including industrial and household chemicals, fertilizers, pesticides, chemicals contained in products and in wastes, prescription and over-the-counter drug products and dietary supplements, and unintentionally produced byproducts of industrial processes or incineration, like dioxins. Furthermore, nanomaterials may need explicit regulation beyond existing frameworks.

Strategic approach to international chemicals management

  1. Worldwide hazardous environmental contamination persists despite several international agreements on chemicals, making a more comprehensive approach to chemicals essential. Reasons for ongoing contamination include persistence of companies, absolute lack of controls in some countries, lack of awareness of the potential hazards, inability to apply the precautionary principle, non-adherence to the various conventions and treaties and lack of political will. The Strategic Approach to International Chemicals Management (SAICM) was adopted in Dubai, on February 6, 2006 by delegates from over 100 governments and representatives of civil society. This is a voluntary global plan of action designed to assure the sound management of chemicals throughout their life cycle so that, by 2020, chemicals are used and produced in ways that minimize significant adverse effects on human health and the environment. The SAICM addresses both agricultural and industrial chemicals, covers all stages of the chemical life cycle of manufacture, use and disposal, and includes chemicals in products and in wastes.

Plastic waste

  1. Plastic has been part of life for more than 100 years and is regularly used in some form by nearly everyone. While some biodegradable varieties are being developed, most plastics break down very slowly with the decomposition process taking hundreds of years. This means that most plastics that have ever been manufactured are still on Earth, unless they have been burnt, thus polluting the atmosphere with poisonous smoke.
  2. Concerns about the use of plastic include accumulation of waste in landfills and in natural habitats, terrestrial and marine, physical problems for wildlife resulting from ingestion or entanglement in plastic, the leaching of chemicals from plastic products and the potential for plastics to transfer chemicals to wildlife and humans. Many plastics in use today are halogenated plastics or contain other additives used in production, that have potentially harmful effects on health (e.g. carcinogenic or promoting endocrine disruption).
  3. Our current usage of plastic is not sustainable, accumulating waste and therefore contributing to environmental degradation and potentially harmful effects on health. Specific regulation is therefore needed to counter the harmful distribution of slowly degradable plastic waste into the environment and the incineration of such waste which often creates toxic byproducts.

WORLD MEDICAL ASSOCIATION (WMA) RECOMMENDATIONS

  1. Despite national and international initiatives, chemical contamination of the environment due to inadequately controlled production and usage continues to exert harmful effects on global public health. Evidence linking some chemicals to some health issues is strong, but far from all chemicals have been tested for their health or environmental impacts. This is especially true for newer chemicals or nano materials, particularly at low doses over long periods of time. Plastic contamination of our natural environment, including in the sea where plastic decomposes to minute particles, is an additional area of serious concern. Physicians and the healthcare sector are frequently required to make decisions concerning individual patients and the public as a whole based on existing data. Physicians therefore recognize that they, too, have a significant role to play in closing the gap between policy formation and chemicals management and in reducing risks to human health.
  2. The World Medical Association reaffirms its commitment to advocate for the environment in order to protect health and life, and recommends that:

ADVOCACY

  1. National Medical Associations (NMAs) advocate for legislation that reduces chemical pollution, enhances the responsibities of chemical manufacturers, reduces human exposure to chemicals, detects and monitors harmful chemicals in both humans and the environment, and mitigates the health effects of toxic exposures with special attention to fertility for women and men and vulnerability during pregnancy and early childhood.
  2. NMAs urge their governments to support international efforts to restrict chemical pollution through safe management, or phase out and safer substitution when unmanageable (e.g. asbestos), with particular attention to developed countries aiding developing countries to achieve a safe environment and good health for all.
  3. NMAs facilitate better inter-sectoral collaboration between government ministries/departments responsible for the environment and public health.
  4. NMAs promote public awareness about hazards associated with chemicals (including plastics) and what can be done about it.
  5. Modern medical diagnosis and treatment relies heavily on the single use of packaged clean or sterile materials with various plastic components, whether the device itself or its packaging. NMAs should encourage research and the dissemination of practices that can reduce or eliminate this component of environmental degradation.
  6. Physicians and their medical associations advocate for environmental protection, disclosure of product constituents, sustainable development, green chemistry and green hospitals within their communities, countries and regions.
  7. Physicians and their medical associations should support the phase out of mercury and persistent bioaccumulative and toxic chemicals in health care devices and products and avoid incineration of wastes from these products which may create further toxic pollution.
  8. Physicians and their medical associations should support the Globally Harmonized System of Classification and Labelling of Chemicals (GHS) and legislation to require an environmental and health impact assessment prior to the introduction of a new chemical or a new industrial facility.
  9. Physicians should encourage the publication of evidence of the effects of different chemicals and plastics, and dosages on human health and the environment.  These publications should be accessible internationally and readily available to media, non-governmental organizations (NGOs) and concerned citizens locally.
  10. Physicians and their medical associations should advocate for the development of effective and safe systems to collect and dispose of pharmaceuticals that are not consumed. They should also advocate for the introduction worldwide of efficient systems to collect and dispose of plastic waste.
  11. Physicians and their medical associations should encourage efforts to curb the manufacture and use of plastic packaging and plastic bags, to halt the introduction of plastic waste into the environment, and to phase out and replace plastics with more biocompatible materials. These efforts may include measures to enhance recycling and specific regulations limiting the use of plastic packaging and plastic bags.
  12. Physicians and their medical associations should support efforts to rehabilitate or clean areas of environmental degradation based on a “polluter pays” and precautionary principles and ensure that moving forward, such principles are built into legislation.
  13. The WMA, NMAs and physicians should urge governments to collaborate within and between departments to ensure coherent regulations are developed.

LEADERSHIP

The WMA:

  1. Supports the goals of the Strategic Approach to International Chemicals Management (SAICM), which promotes best practices in the handling of chemicals by utilizing safer substitution, waste reduction, sustainable non-toxic building, recycling, as well as safe and sustainable waste handling in the health care sector.
  2. Cautions that these chemical practices must be coordinated with efforts to reduce greenhouse gas emissions from health care and other sources to mitigate its contribution to global warming.
  3. Urges physicians, medical associations and countries to work collaboratively to develop systems for event alerts to ensure that health care systems and physicians are aware of high-risk industrial accidents as they occur, and receive timely and accurate information regarding the management of these emergencies.
  4. Urges local, national and international organizations to focus on sustainable production, safer substitution, green safe jobs, and consultation with the health care community to ensure that damaging health impacts of development are anticipated and minimized.
  5. Emphasizes the importance of the safe disposal of pharmaceuticals as one aspect of health care’s responsibility and the need for collaborative work in developing best practice models to reduce this part of the chemical waste problem.
  6. Encourages environmental classification of pharmaceuticals in order to stimulate prescription of environmentally less harmful pharmaceuticals.
  7. Encourages local, national and international efforts to reduce the use of plastic packaging and plastic bags.
  8. Encourages ongoing outcomes research on the impact of regulations and monitoring of chemicals on human health and the environment.

The WMA recommends that Physicians:

  1. Work to reduce toxic medical waste and exposures within their professional settings as part of the World Health Professional Alliance’s campaign for Positive Practice Environments.
  2. Work to provide information on the health impacts associated with exposure to toxic chemicals, how to reduce patient exposure to specific agents and encourage behaviors that improve overall health.
  3. Inform patients about the importance of safe disposal of pharmaceuticals that are not consumed.
  4. Work with others to help address the gaps in research regarding the environment and health (i.e., patterns and burden of disease attributed to environmental degradation; community and household impacts of industrial chemicals; the effects, including on health, of distribution of plastic and of plastic waste into our natural environment; the most vulnerable populations and protections for such populations).

PROFESSIONAL EDUCATION & CAPACITY BUILDING

The WMA recommends that:

  1. Physicians and their professional associations assist in building professional and public awareness of the importance of the environment and global chemical pollutants on personal health.
  2. NMAs develop tools for physicians to help assess their patients’ risk from chemical exposures.
  3. Physicians and their medical associations develop locally appropriate continuing medical education on the clinical signs, diagnosis, treatment and prevention of diseases that are introduced into communities as a result of chemical pollution and exacerbated by climate change.
  4. Environmental health and occupational medicine should become a core theme in medical education.  Medical schools should encourage the training of sufficient specialists in environmental health and occupational medicine.

Adopted by the 48th WMA General Assembly, Somerset West, South Africa, October 1996,
editorially revised by the 174th WMA Council Session, Pilanesberg, South Africa, October 2006,
amended by the 61st WMA General Assembly, Vancouver, Canada, October 2010
and by the 72nd WMA General Assembly (online), London, United Kingdom, October 2021 

 

PREAMBLE

Family violence is a grave universal public health and human rights problem that affects individuals, regardless of age, gender, sexual orientation, racial/ethnic background, culture, religion, socio-economic status or any other factor. 

Though definitions vary, the term family violence is generally applied to the physical, sexual, verbal, economic, spiritual, psychological or emotional abuse, or neglect of a person by someone with whom the victim is physically, financially, emotionally or socially related and/or dependent. 

Although the causes of family violence are complex, a number of contributing factors are known, such as lack of basic education, lack of economic independence/poverty, underlying and/or undiagnosed mental health issues, substance abuse (particularly alcohol), stress, rigid gender roles, poor parenting skills, interpersonal conflicts within the family, the perpetrator’s experience of maltreatment and family violence as a child, or familial social isolation. 

Family violence has adverse physical, mental, emotional and psycho-social consequences on the individual and negatively impacts the health and wellbeing of the affected individual. There may also be socio-economic impacts as well as impacts on a witness of family violence, the family and community. These adverse effects could be short-term/immediate or long-term/chronic. They include physical harm/injuries, death, impact on reproductive health/miscarriage, dysfunctional families, educational disruptions and poor academic performance, sexually transmitted diseases, juvenile delinquency, professional disruptions and loss of employment, social exclusions and homelessness, insomnia, anxiety, depression, resort to substance abuse and crime, post-traumatic stress disorder, and suicide. Victims can become perpetrators of family violence and violent acts against non-intimates (intergenerational transmission of violence). 

 The World Medical Association (WMA) firmly condemns all forms of violence and reaffirms its policies on Violence against Women and Girls, Child Abuse and Neglect, the Abuse of the Elderly, and Violence and Health. 

 

RECOMMENDATIONS 

 Governments and National Health Authorities  

WMA urges governments to: 

  1. Strengthen the sense of social responsibility, develop and enforce policies, legal frameworks, and national plans with allocated budget for the prevention and elimination of family violence, as well as for protection of victims and witnesses of family violence.
  2. Address the root causes of violence in relation to social determinants of health and to promote health equity. This should include addressing gender inequality and other harmful societal practices.
  3. Recognise that times of intense individual and/or national stress increase the risk of family violence and ensure that appropriate resources are publicized and made available during such times.
  4. Provide tools to recognize, act upon and if necessary report cases of family violence.
  5. Develop data collection systems on family violence, that holistically include vital aspects of family violence such as mortality, morbidity, injuries, family or community environment, risk factors, costs of interventions, loss in productivity, legal costs among others.
  6. Provide secure private reporting mechanisms and safe havens to protect the individual from feelings of guilt and shame to avoid stigma and retaliation.
  7. Require a guideline that indicates how to act on suspicion of family violence and what interventions are available. Reporting should only be done when, in the opinion of the physician, doing so will not endanger the individual experiencing the violence. If possible, this should be done in consultation with the individual experiencing the violence.
  8. Institute and promote high-quality research programs to provide a strong evidence base on the multiple facets of family violence such as the magnitude, risk profiles, underlying factors, and the complex interplay of factors, as well as cross comparisons among settings, countries and regions.
  9. Develop and offer family violence services to those experiencing family violence, including policy and legal accompaniments, case management, advocacy, counselling, safe housing and safety planning.
  10. Encourage multi-stakeholder constructive collaboration between sectors, disciplines, as well as governmental and nongovernmental bodies, including traditional and religious institutions, to eliminate and prevent family violence.

WMA constituent members and the medical profession

WMA constituent members should :

  1. Encourage coordination of action against family violence between and among components of the health care system, criminal justice systems and law enforcement authorities, including family and juvenile courts, and victims’ services organizations.
  2. Encourage and facilitate research to understand the prevalence, risk factors, outcomes and optimal care for victims of family violence.
  3. Promote advocacy, public and professional awareness creation, and community education programs on family violence.
  4. Encourage managers of public and private health facilities to provide educational materials in reception/patient waiting rooms and emergency departments, to offer patients and clients general information about family violence, as well as to inform them about available integrated and professionally good local services that can be accessed.
  5. Advocate for inclusion of courses on violence, including family violence, in the academic curricula for undergraduate and postgraduate medical education.
  6. Promote capacity building and Continuous Medical Education programs for physicians, on prevention of family violence.
  7. Advocate for rehabilitation, counseling, and therapy to those who either cause, experience or are exposed to the violent acts, especially traumatized children.
  8. Encourage adequate undergraduate family medicine education and training in family dynamics, including the medical, sociological, psychological and preventive aspects of all types of family violence. 

Physicians 

In the light of their obligation to promote the well-being of patients, physicians have an ethical obligation to take appropriate action to recognize and offer assistance to patients harmed by family violence and abuse.

Physicians should:

  1. Routinely consider and be sensitive to signs indicating the need for further evaluations about current or past abuse as part of their general health screening or in response to suggestive clinical findings, as physicians are often the first to suspect family violence.
  2. Be acquainted on ways to take an appropriate and culturally sensitive history of current and past abuse and be acutely aware of the need to maintain confidentiality and a trusting patient-physician relationship in cases of family violence.
  3. Be aware of social, community and other services useful for victims, and in some cases, perpetrators of violence and refer to and use these routinely to support victims, witnesses and/or perpetrators of family violence.
  4. Report suspected violence against children and other family members to appropriate protection and security services in keeping with applicable requirements, and take necessary measures to ensure that victims and witnesses of violence are not at risk.
  5. Be encouraged to participate in coordinated community activities that seek to reduce the burden and impact of family violence.
  6. Be encouraged to embrace patient-centred, community specific care, and to develop impartial attitudes toward those involved in family violence. 

 

Adopted by the 51st World Medical Assembly, Tel Aviv, Israel, October 1999
revised by the 61st WMA General Assembly, Vancouver, Canada, October 2010
and reaffirmed with minor revisions by the 215th Council session (online), Cordoba, Spain, October 2020

 

PREAMBLE

The goal of pharmacological treatment is to improve patients´ health and quality of life. Optimal pharmacological treatment should be safe, effective and efficient. There should be equity of access to this kind of treatment and an accurate and up-to-date information base that meets the needs of patients and practitioners.

Pharmacological treatment has become increasingly complex, often requiring the input of a multi-disciplinary team to administer and monitor the chosen therapy. In the hospital setting the inclusion of a clinical pharmacist in such a team is increasingly common and helpful. The right to prescribe medicine should be competency based and ideally the responsibility of the physician.

Physicians and pharmacists have complementary and supportive responsibilities in achieving the goal of providing optimal pharmacological treatment. This requires communication, respect, trust and mutual recognition of each other’s professional competence. Access by both physicians and pharmacists to the same accurate and up-to-date information base is important to avoid providing patients with conflicting information.

Physicians and pharmacists must provide quality service to their patients and ensure safe use of drugs. Therefore, collaboration between these professions is imperative, including with respect to the development of training and in terms of information sharing with one another and with patients. It is necessary to keep an open and continued dialogue between physicians’ and pharmacists’ representative organizations in order to define each profession’s respective functions and promote the optimal use of drugs within a framework of transparency and cooperation, all in the best interests of patients.

The Joint Statement on Counterfeiting Medical Products of the World Health Professions Alliance (WHPA) states that physicians and pharmacists share the same priority of identifying, investigating and eliminating counterfeit medicines, in which both physicians and pharmacists play a crucial role.

Patients are best served when pharmacists and physicians collaborate, recognizing and respecting each other’s roles, to ensure that medicines are used safely and appropriately to achieve the best outcome for the patient’s health.

 

THE PHYSICIAN’S RESPONSIBILITIES

  1. Diagnosing diseases on the basis of the physician’s education and specialized skills and competence.
  2. Assessing the need for pharmacological treatment and prescribing the corresponding medicines in consultation with patients, pharmacists and other health care professionals, when appropriate.
  3. Providing information to patients about diagnosis, indications and treatment goals, as well as action, benefits, risks and potential side effects of pharmacological treatment. In the case of off-label prescriptions the patient must be informed about the character of the prescription.
  4. Monitoring and assessing response to pharmacological treatment, progress toward therapeutic goals, and, as necessary, revising the therapeutic plan in collaboration with pharmacists, other health professionals and, when appropriate, caregivers.
  5. Providing and sharing information in relation to pharmacological treatment with other health care practitioners.
  6. Leading the multi-disciplinary team of health professionals responsible for managing complex pharmacological treatment.
  7. Maintaining adequate records for each patient, according to the need for therapy and in compliance with legislation respecting confidentiality and protecting the patient’s data.
  8. Where practically possible, actively participating in establishing electronic drug delivery systems within their workplace and supporting those systems with their professional knowledge.
  9. Maintaining a high level of knowledge of pharmacological treatment through continuing professional development.
  10. Ensuring safe procurement and storage of medicines that the physician is required to supply or permitted to dispense.
  11. Reviewing prescription orders to identify interactions, allergic reactions, contra-indications and therapeutic duplications.
  12. Reporting adverse reactions to medicines to health authorities, in accordance with national legislation.
  13. Monitoring and limiting, where appropriate, prescriptions of medications that may have addictive properties.
  14. Documenting adverse reactions to medicines in the patient’s medical record.

THE PHARMACIST’S RESPONSIBILITIES

  1. Ensuring safe procurement, adequate storage and dispensing of medicines in compliance with the relevant regulations.
  2. Providing information to patients, which may include the information leaflet, name of the medicine, its purpose, potential interactions and side effects, as well as correct usage and storage.
  3. Reviewing prescription orders to identify interactions, allergic reactions, contra-indications and therapeutic duplications. Concerns should be discussed with the prescribing physician but the pharmacist should not change the prescription without consulting the prescriber.
  4. Discussing medicine-related problems or concerns with regard to the prescribed medicines when appropriate and when requested by the patient.
  5. Advising patients, when appropriate, on the selection and the use of non-prescription medicines and the patient’s management of minor symptoms or ailments. Where self-medication is not appropriate, advising patients to consult their physician for diagnosis and treatment.
  6. Participating in multi-disciplinary teams concerning complex pharmacological treatment in collaboration with physicians and other health care providers, typically in a hospital setting.
  7. Reporting adverse reactions to medicines to the prescribing physician and to health authorities in accordance with national legislation.
  8. Providing and sharing general as well as specific medicine-related information and advice with the public and health care practitioners.
  9. Maintaining a high level of knowledge of pharmacological treatment through continuing professional development.

Adopted by the 50th World Medical Assembly, Ottawa, Canada, October 1998,
reaffirmed by the 59th WMA General Assembly, Seoul, Korea, October 2008,
amended by the 61st WMA General Assembly, Vancouver, Canada, October 2010,
and by the 72nd WMA General Assembly (online), London, United Kingdom, October 2021 

 

PREAMBLE

For the purpose of this Statement, in line with the International Organisation for Migration index, “migrant” is an umbrella term reflecting the common lay understanding of a person who moves away from his or her place of usual residence, whether within a country or across an international border, temporarily or permanently, and for a variety of reasons.   

The WMA considers health to be a basic need, a human right, and one of the essential drivers of economic and social development.  

According to the World Health Organisation, universal access to health implies that all people and communities have access to comprehensive health services, without barriers or discrimination, according to their needs, within the framework of equitable and supportive health systems.   

Recalling the WMA Declaration of Geneva, the WMA underlines every physician’s duty to not permit considerations of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, social standing or any other factor to interfere with the physician’s duty to his or her patient.   

The WMA underlines that physicians should offer help in medical emergencies in accordance with the WMA International Code of Medical Ethics. 

Taking into account the WMA Declaration of Ottawa on Child Health and the WMA Statement on Medical Age Assessment of Unaccompanied Minor Asylum Seekers, the WMA reiterates that children should enjoy special protection, including the right to adequate health care without discrimination. 

These fundamental WMA principles also echo the principles laid down in the Universal Declaration of Human Rights, the United Nations Convention on the Rights of the Child and the International Covenant on Economic, Social and Cultural Rights.  

The WMA Declaration of Lisbon on the Rights of the Patient declares that every person is entitled without discrimination to appropriate medical care. However, national legislation varies and is often not in accordance with this fundamental principle. 

At any time, large numbers of migrants are seeking protection, fleeing from natural disasters, desperate poverty, violence and other injustices and abuses with potentially very harmful effects to mental and physical health. 

Recalling the WMA statement on Armed Conflicts and the WMA declaration on Health and Climate Change, the WMA recognizes that climate change, natural disasters, warfare, armed conflicts and other emergencies, including continuous civil strife, unrest and violence, will inevitably lead to the displacement of people from their homes.   

The WMA is concerned by the precarious situation of certain categories of migrants, such as refugees, asylum seekers, refused asylum seekers, undocumented migrants and displaced persons, whose access to health care is often undermined, and where physicians are required in some countries to intervene outside the scope of their medical duty, in contradiction with medical ethics.  

Bearing in mind the above-mentioned principles, international conventions and WMA policies, the WMA advocates a strong and continued engagement of physicians in the defence of human rights and dignity of all people including migrants worldwide, while making the following recommendations for its constituent members and individual physicians: 

 

RECOMMENDATIONS  

WMA constituent members should: 

  • Prioritize the medical care of human beings above any other personal, material, economic, or political interest. 
  • Actively support and promote the right of all people to receive medical care on the basis of clinical need alone and speak out against legislation and practices that contradict this fundamental right. 
  • Call for governments to reach political agreements that facilitate the availability of sufficient resources for the delivery of adequate and coordinated health services to migrant populations, including in refugee camps where the conditions of living make them more susceptible to the spread of disease and viruses. 
  • Urge governments to ensure access to safe and adequate living conditions and essential services to all migrants, even with support from the donor agencies and/or philanthropists if needed. 
  • Promote equality, solidarity and social justice, guaranteeing access of migrants and refugees to health and social services. 
  • Implement policies, actions and commitments that promote the health of all, without discrimination, addressing the social determinants of health related to migrants and refugees. 

Physicians: 

  • Have a duty to provide appropriate medical care, based solely on clinical need, regardless of the civil or political status of the patient. 
  • Should speak out against legislation and practices that prevent the fulfilment of this duty. 
  • Cannot be compelled to participate in any punitive or judicial action against migrants, including refugees, asylum seekers, refused asylum seekers, undocumented migrants and or displaced persons, or to withhold medically necessary treatment, or to administer any non-medically justified diagnostic measure or treatment, such as sedatives to facilitate easy deportation from the country or relocation. 
  • Must be allowed adequate time and be provided with sufficient resources, including interpretation services, to assess the physical and psychological condition of migrants, including refugees, asylum seekers, refused asylum seekers, undocumented migrants and displaced persons.